document (5)
DESCRIPTION
load carriage, exercise, fitness, health, tacticalTRANSCRIPT
![Page 1: Document (5)](https://reader031.vdocuments.mx/reader031/viewer/2022020812/563db8e9550346aa9a982989/html5/thumbnails/1.jpg)
7/17/2019 Document (5)
http://slidepdf.com/reader/full/document-5-568e0f0846ef7 1/6
DICINE
176, 9:1027, 2011
Effect of Load Carriage on Performance of an Explosive
Anaerobic Military Task
Alison K, Laing
Treloar
BAppSci Ex Sp Sc)
(Hons);
Daniel C Billing, P hD
AB ST RA CT This study examined tbe effects of load carriage on performance of an explosive, anaerobic tnilitary
task. A task-specific assessment requiring five 30-m timed sprints was developed to address this question. Seventeen
soldiers (female = 5, male = 12) volunteered to undergo the test under two experimental conditions; unloaded (cotnbat
uniform and boots) and loaded (unloaded plus 21.6 kg fighting load, comprising webbing, weapon, helmet, and combat
body armor). When loaded, there was a significant increase in tbe mean 30-m sprint time compared to unloaded (8.2 ±
1.4 seconds vs. 6.2 ± 0.8 seconds; p 0.01). Of the total increase in mean sprint time, 51.7% occurred within the first
5 m. Fetnale sprint times were affected to a larger extent than m ale (36% vs. 29 %, respectively) as a result of the increased
load. Fighting load significantly affected soldier mobility when conducting explosive, anaerobic military tasks, particu-
larly among females, and specific physical conditioning should be considered to minimize this effect.
10 and 15 kg. In addi-
a soldier in fighting load is required to carry a weapon,
The effects of load carriage on the performance of explo-
Consequently, there is a clear need to directly measure the
y to assess the impact of load under these conditions.
The only formal test within the Australian Army to assess
Defence Science and Technology Organisation, 506 Loritner Street,
Jump (RDJ). This requires negotiation of a series of obsta-
cles within a set time frame. As with the tasks highlighted
above, the similarity between this obstacle course and critical
defensive military tasks is unknown. Further, successful per-
formance is dictated to a large extent by skill' and anthropo-
métrie characteristics.* Considerable attention has been given
to the developm ent of obstac le courses in the past*^'' how ever
these pose the same problems as the RDJ.
A review of the training processes within the Australian
Army and consultation with military staff indicated that the
minimum anaerobic requirement for a soldier, irrespective of
age, sex, or occupationa l specialty, was the successful perfor-
mance of a defensive withdrawal under fire. This task is typi-
cally achieved using a break contact drill (BCD), a maneuver
recommended for withdrawing frotn an enetny when engage-
ment is not desired. Soldiers conducting a BCD alternate
between prov iding covering fire and sprinting down a corridor
of section mem bers, allowing a distinct separation of physical
and skill components. Furthermore, the BCD forms the basis
of other repeat sprint, fire-and-movement activities that may
be encountered by soldiers, such as during a vehicle atnbush
or urban-based operations.
This article aims to determine the impact of load carriage
on performance of explosive, anaerobic tnilitary tasks and to
identify any sex-based differences. The first part of this article
is concerned with the development of a valid assessment of
the performance of a high intensity, explosive military task.
A test based on the BCD would en sure the minimum physical
capacity com mensu rate with the performance of critical etner-
gency/defensive duties is assessed. This test is then imple-
mented in the second part of the article to answer the primaty
research question.
METHOD
Experimental procedures were approved by the Australian
Defence Human Research Ethics Comtnittee. All participants
![Page 2: Document (5)](https://reader031.vdocuments.mx/reader031/viewer/2022020812/563db8e9550346aa9a982989/html5/thumbnails/2.jpg)
7/17/2019 Document (5)
http://slidepdf.com/reader/full/document-5-568e0f0846ef7 2/6
Effect of Load arriage on Mobility
were fully briefed and provided written and informed
eonsent.
Part : Developm ent of a Va lid Test for the B CD
Development of an anaerobie test based on the BCD occurred
over multiple stages. First, subject matter experts of various
ranks were consulted to determine the tactical requ irements of
the task aceording to standard operating proeedures to define
a realistic operational scenario under which the task would
be performed. Second, a series of staged observations of the
BCD were conducted. Sixteen infantrymen, whose mean age
and infantry experience (range) was 24.5 (19-35) years and
2.3 (0.1-8) years, respectively, performed the maneuvers.
Under instruction from their Commanding Officer (CO), the
soldiers performed, as part of two
8 man
sections, three simu-
lated secure withdrawals each using a BCD. The BCDs were
simulated by the CO to accurately refleet typieal conditions
and movements.
The BCDs were completed in fighting load, with soldiers
instrueted to present with 21.6 kg of equipment. After an activ-
ity briefing was given by the CO, body mass and the weight
of soldiers' equipment were collected to eonfirm fighting load
weight. Each BCD was separated by approximately 7-minute
rest. Each soldier carried a global positioning system (GPS)
(FRWD B-series; FRWD Technologies, Oulu, Finland), whieh
logged eoordinates every second, and the activity was video-
taped (Hard Dise Camcorder GZ-MG50AA; JVC, Yokohama,
Japan).
Data colleeted by GPS was analyzed using FRWD propri-
etary software (FRWD Pro Replayer 2.5; FRWD Technolo-
gies). It was possible to quantify the total time taken and
distance eovered in each BCD, as well as the number of
eomponent sprint bouts. Beeause of the GPS resolution, it
was not possible to determine distance of individual sprint
bouts. Instead, video data was used to calculate the typical
work-to-rest ratio. Time spent sprinting and resting (firing
down range) for each bout was then calculated by applying
the work-to-rest ratio and the number of sprint bouts to the
BCD duration. Distance of each sprint bout was calculated
by dividing total distance covered by the number of sprint
bouts. The resulting test was a praetieal simulation based on
these parameters.
Part : Effect of Load on the Performance o f the
BCD Simulation Assessment
Seventeen soldiers (female = 5, male = 12) from a broad cross-
section of oeeupational speeialties, including cooks, drivers,
medics, and clerks, participated in this part of the study. All
soldiers were qualified in their respective trades, with a mean
of 3.0 (0.25-18) years experienee since completing trade-
training; however, no soldier had specific combat experienee
nor experience wearing CBA. The mean age, body mass, and
height were, respectively, 23.1 (18-40) years, 78.2 ± 13.0 kg,
and 178.6 + 7.1 cm (±SD ).
On day 1, the soldiers were briefed and weighed be
undertaking the counter movetnent vertical jum p test w
ing combat uniform and boots to assess lower limb pow
Soldiers returned
2
to
3
days later
to
undertake the BCD ass
ment. The assessment was eonducted in unloaded and loa
conditions across 2 days, with 5 days rest between each t
In both conditions, soldiers wore combat uniform and bo
with an additional 21.6 kg (webbing, weapon, CBA, and h
met) when loaded.
Eaeh testing day began with a standardized warm-up in
porating the eonstruct and movement patterns of the ass
ment for familiarization purposes. Equipment weight
cheeked and adjusted for accuracy eaeh morning. Soldiers t
completed the BCD test, whieh eonsisted of 5 x 30-m spr
at 44-second intervals (Fig. 1), on a grass surface. The in
vals were timed by a custom digital audio track, and sold
were required to start from the prone firing position. Sold
adopted the prone position when the audio track indica
10 seeonds before sprint start. A verbal eountdown from 3
minimize the effeets of reaction time, preeeded a starting
nal. Soldiers were instrueted to complete eaeh sprint at t
maximum speed. Split times were measured at 5-, 10-,
20-, and 30-m intervals with timing gates accurate to 0.01
onds (G-Speed 100; Onspot, Barrack Heights, Australia).
prone starting position made it necessary for the timing g
to be manually started by a member of the research team
line with the audio track.
The performance time for each condition was taken as
mean of
the
five 30-m sprint times. Split times were calcul
in a similar manner. Mean p erfonnance time was used to m
imize the effeets of both the soldiers and the timing sys
operato r from starting before or after the beep .
A two-way repeated measures analysis of variance (ANO
(order x condition) was used to detect any order eff
across sprints
to 5, in both unloaded and loaded conditi
A two-way ANOVA (load x sex) was then used to eval
the effeets of an additional 21.6-kg load on mean sprint t
and to identify any signifieant sex-based interactions.
individual comparisons were isolated using Tukey's hone
significant difference (HSD) post hoc comparisons. R
tionships between mean sprint time and body mass, and m
sprint time and vertical jump performance were indicated
Pearson 's correlation coefficient for both u nloaded and loa
eonditions.
5 m 10 m 15 m 20 m 3
FIG UR E 1. Illustration of BCD assessment and split time intervals.
![Page 3: Document (5)](https://reader031.vdocuments.mx/reader031/viewer/2022020812/563db8e9550346aa9a982989/html5/thumbnails/3.jpg)
7/17/2019 Document (5)
http://slidepdf.com/reader/full/document-5-568e0f0846ef7 3/6
Effect of Load Carriage on Mob ility
RESULTS
Part One Developm ent of a Va lid Test for the BCD
The actual fighting load weight carried by infantrymen dur-
ing the BCD was 22.4 ± 2.5 kg. Table I details mean values
for key task parameters. From the GPS data, total task dura-
ion and distance covered for each BCD was determined, as
ell as the number of component sprint bouts performed by
firing down range). The activity was conducted in light scrub
est ratios were based upon movements for which a complete
ycle of sprint and rest was visible. Considering the variables
surrounding the task in an operational setting, it was felt that
his analysis appropriately indicated the work-to-rest require-
ments. Changing the environmental profile to allow better
oldier visibility would have changed the nature of the fire-
Parameters presented in Table I were used to form the basis
a BCD assessment. Minor adjustments ensured the test was
cal and easily implemented. It was assumed participants
to 5, although the distanee
assessments developed'^ as a guideline.
n no more than 9 seeonds to ensure the op erational sce-
ted to maintain the app roximate w ork-to-rest ratio.
participants were required to complete their five 30-m
e of one every 44 seco nds.
TABLE I.
BCD Parameters
a
b
c
d
e
f
g
BCD Duration (Seconds)
BCD Distance (m)
No.
of Sprint Bouts BCD
Work-to-Rest Ratio
Sprint Bout Distance (m) (b/c)
Sprint Bout Duration (Seconds) ([a x d]/c)
Sprinting Speed (m s ') (e/0
174 ± 3 8
129,6 ±21,8 0
4,3 ± 1,0
l;4
30,8
10,1
3,1
Soldiers completing the BCDs varied between firing from
the kneeling position and firing from the prone position.
Consultation with the CO indicated that all soldiers should be
capable of going to ground, and thus it was determined that
all sprints within the BCD assessment would begin from the
prone position. For safety reasons, soldiers were not expected
to go to ground at the completion of each 30-m sprint, instead
they were to decelerate gradually and return to the starting
position.
Part Two Effect of Load on the Performan ce of the
BCD Assessment
A
repeated measures ANOVA found significant order effects
across sprint repetitions 1 to 5 in the unloaded condition p
<
0.05); however, Tuk ey's H SD did not identify significant
differences between any of the sprint repetitions (Table II).
A significant order effect was also present in the loaded eon-
dition p 0.01). According to Tukey's HSD, sprint repetition
1 (8.0 ± 1.3 seeonds) was statistically faster than sprint repeti-
tions 3 (8.3 ± 1.5 seconds), 4 (8.4 ± 1.4 seeonds), and 5 (8.3 ±
1.4 seconds) and sprint repetition 2 (8.1 ± 1.4 seconds) was
statistically faster than sprint repetition 4. Mean performance
time of the 5 sprints will be used for subsequent analysis of
the main effect of 21.6 kg on BCD performance.
Overall, the additional load increased the mean 30-m-sprint
performance time by 2.0 ± 0.6 seconds
(31.5%;
p < 0.01) per
sprint bout (Table II). With a mean sprint time of 8.19 seconds
in the loaded condition, 14 of 17 soldiers met the performanee
criteria of 9 seeonds or less. The implications of heavy fight-
ing loads on an explosive anaerobic task could substantially
affect a soldier's survivability.
Females were slower in both unloaded and loaded condi-
tions compared to males, and there was a significant sex by
condition interaction
p <
0.01). M ales and females had a
1.7 ± 0.4 seconds and 2.5 ± 0.7 seeonds inerease in mean
sprint time, respectively, w hich translates to a 3 6% increase in
mean sprint time for females, compared with 29% for males.
Time to completion was further analyzed by investigat-
ing split times across eomponents of the sprint (Table
III .
The increase in sprint time is evident at all splits; however,
51.7%
of the total performance loss is attributable to the first
5 m, indicating a slower starting momentum when raising the
heavy load from the ground and initiating the sprint.
Body mass was not eorrelated with BCD performance
(
O
'loaded = 0-1
);
however, a significant eon-elation
TABLE II
Mean BCD Sprint Times (Seconds ± SD) for Males and Females in the Unloaded (UNL) and Loaded (LD) Conditions
Males
Females
Overall
UN L
LD
UN L
LD
UN L
LD
Sprint 1
5,8 ± 0,5
7,4 ±0,8
7,1 ± 1,0
9,3 ± 1,5
6,2 ± 0,8
8,0 ± 1,3
Sprint 2
5,8 ±0,5
7,5 ±0,8
7,0 ± 1,0
9,5 ± 1,5
6,2 ±0,8
8,1 ± 1,4
Sprint 3
5,9 ±0,4
7,6 ±0,7
7,1 ± 1,0
9,8 ± 1,9
6,2 ± 0,8
8,3 ± 1,5
Sprint 4
5,9 ± 0,4
7,8 ±0,8
7,1 ± 1,0
9,8 ± 1,4
6,3 ± 0,8
8,4 ± 1,4
Sprint 5
5,9 ±0,4
7,6 ±0,7
7,2 ± 1,0
9,7 ± 1,7
6,3 ± 0,8
8,2 ± 1,4
Average
5,9 ± 0,4
7,6 ± 0,7
7,1 ± 1,0
9,6 ± 1,6
6,2 ± 0,8
8,2 ± 1,4
![Page 4: Document (5)](https://reader031.vdocuments.mx/reader031/viewer/2022020812/563db8e9550346aa9a982989/html5/thumbnails/4.jpg)
7/17/2019 Document (5)
http://slidepdf.com/reader/full/document-5-568e0f0846ef7 4/6
Effect of Load Carriage on M obility
TABLE III. Mean BCD Split Titnes (Seconds ± SD) for the
Unloaded and Loaded Conditions
Split (m)
0- 5
5-10
10-15
15-20
20-30
0-30
UN L
(Seconds ± SD)
2 2
± 0.4
9
±0.1
0.8 ±0.1
0.8 ±0.1
1.6 ±0.2
6,2 0,8
LD
(Seconds ± SD)
3 2
± 0.8
1.1
±0.1
2
±0.1
2
±0.1
1.9 ±0.3
8,2 ±
1.4
Difference
(Seconds ± SD)
1.0 ±1 .0 45.5%
0.2 ±0 1 21.04%
0.2 ±0.1 22.93%
0.2 ±0 .1 24.61%
0.4 ±0 1
25.03%
2,0 ± 0,6 31,47
was found between vertical jump and BCD performance
(r - 0 . 8 ; p 0,01 for both loaded and unloaded conditions).
IS USSION
Although the effects of load carriage on military endurance
tasks such as marching have been extensively evaluated,
there is limited research investigating the effects of a fight-
ing load on the performance of a simulated high intensity,
short duration military task, A face-valid assessment, based
directly on the performance of a defensive withdrawal under
fire, was develop ed to address this question, Wh en performing
this BCD assessment, the addition of a 21,6 kg fighting load
increases average sprint bout time in the BCD assessment by
31,5%. This is a substantial decrement in performance, par-
ticularly when considering soldiers may perform 4 to 5 sprint
bouts per BCD,
It is evident that all sprint split times, from 0 to 30 m, were
impacted upon when com paring the loaded and unloaded con -
ditions; however, the greatest decrement in performance was
observed when soldiers are expected to rise from the prone
position and begin sprinting (0-5 m). This is not surprising
given fire-and-movement activities conducted in a loaded
state have previously been correlated with measurements of
both leg power (vertical and horizontal jumps) and push-up
ability,'^
The slower average times of females compared to males
in both conditions is consistent with studies of similar activi-
ties,^''
The greater decrement in performance experienced by
females when carrying a load compared to that of males is
reflective of the work by Nelson and Martin,^ who showed a
consistent increase in performance for 9,1 and 22,9 m sp rints,
long jump,
and agility run. Th e current findings do not provide
sufficient data to identify the mechanisms behind decreased
load carriage ability of wom en. Nev ertheless, the lack of sig-
nificant correlation between loaded sprint performance and
body mass suggests that sex-based effects cannot be exp lained
by the differences in average body mass between males and
females, Wben comparing body mass-matched males and
females, females had a slower average sprint time than their
male counterparts. Sprinting 9,1 and 2 2,9 m with both 17 and
29 kg loads was also shown to be poorly correlated with body
mass in the study completed by Nelson and Martin,' Despite
this absence of significant correlations, these researchers
hypothesized that the different body compositions of ma
and females may still be contributing factors to the sex-bas
effect,'^ Although absolute loads carried were identical, th
was a great difference in load carried relative to lean bo
mass.
However, when relative load was graphically analy
against sprint performance, there was still a clear distinct
between the sexes, suggesting body composition is not
only factor at play. Despite known differences in muscle fo
producing capacity of males and females, a recent revie
has highlighted the need for further investigation into diff
ences between males and females performing multiple-sp
exercise to answer these basic physiological questions.
The observed performance decrement in this study m
have been attenuated had our subjects, both male and fema
been conditioned to wearing CBA; however, this wo
have decreased the applicability of the findings to nonco
bat soldiers within the Australian Army. Noncombat soldi
on their first operational deployment may have little opp
tunity for such familiarization, and the performance dec
ments shown in this study warrant further investigation i
the issue. Familiarization issues can include both equipm
integration, such as CBA and webbing fit, and physical co n
tioning. It is unknown whether specific physical condition
in CBA would decrease the performance difference betw
loaded and unloaded, or simply enhance the performance
both conditions to the same extent. However, either scena
would provide practical and meaningful benefit to the sold
To the auth ors' kn owledg e, no research has been condu c
surrounding conditioning for load carriage during sprinti
however, load-specific task performance'^ and strength tra
ing'^ have both led to improvements in loaded marching p
formance. Strength and power training eould be particula
beneficial given the prone starting requirement and the cor
lation between vertical jump and average sprint performa
found in this study. Furthermore, anaerobic capacity can
significantly improved by intermittent, high intensity tra
ing, '^ which would be highly specific to the BCD 's repea
sprint requirement. Further studies into physical condit
ing and load carriage familiarization would help to indic
whether load tolerance during sprinting can be improved
benefits are confined to overall performance improvemen
The increased sprint time reported in this study is far gre
than that previously reported. Specifically, a 13% increase
80-m sprint time was observed among infantry soldiers w
wearing a 16 kg simulated carrying harness,' whereas
8,7% increase in time to complete 5 continuous 30-m rus
occurred with a load increase of 14 kg,'' Th e load carried in
latter study's control condition was not stated; however,
14-kg increase was comprised of CBA , The smaller loads h
explain the reduced effects on performance; however, w
expressed in per kilogram the performance effects in this st
are still greater (0,6% per kg vs, 1,5% per kg). Subject pop
tion likely contributed to this difference, given male infa
soldiers were used in one instanc e' and Army enlisted ma
in the other,** The performance effects are not as great if
![Page 5: Document (5)](https://reader031.vdocuments.mx/reader031/viewer/2022020812/563db8e9550346aa9a982989/html5/thumbnails/5.jpg)
7/17/2019 Document (5)
http://slidepdf.com/reader/full/document-5-568e0f0846ef7 5/6
Effect of Load arriage on Mobility
oldiers from this study are considered (1.3 per kg);
Prone vs. upright starting positions may also explain some
m 0 to 5 m. N either
y that the carriage of a weapon in the loaded condition of
Given the load carriage effeets discussed in this article, there
ct of load carriage on other
erent webbing configurations, should also
soldier mobility.
The Australian Army's mandatory physical fitness test-
y. The B CD simulation test developed
udy may be used as both an occupational physical fit-
In conclusion, this study indicates that carriage of 21.6-kg
KNOWLEDGMENT
REFEREN ES
1, Danielsson U, Bergh U: Body armour. Effects on performance and
physical load. In: llth International Conference on Environmental
Ergonomics, Edited by Holmer I, Kuklane K, Gao C, Ystad, Sweden,
Freund Publishing House, 2005,
2, Derrick L, Henn HR, Malone GH: The Intluence of Body Armour
Coverage and Weight on the Performance of the Marine While Per-
forming Certain Simulated C ombat-Type Tasks, Vol 13, pp 1-10,
Camp Lejeune, NC, US Naval Medical Field Research Laboratory,
1963,
3, Holewijn M, Lötens WA: The influence of backpack design on physical
performance. Ergonomics 1992; 35: 149-57,
4,
Hasselquist L, Bensel C, Corner B, Gregorczyk K, Schiffman J:
Biomechanical and Physiological Cost of Body Armor, Ann Arbor, Ml,
North American Congress on Biomechanics, 2008,
5,
Nelson RC, Martin PE: Effects of Gender and Load on Combative
Movement Performance, NATICK/TR-82/011, Natick, MA, US Army
Natick Research and Development Laboratories, 1982,
6, Pandorf CE, Harman EA, Frykman PN , Patton JF, Mello RP, Nindl BC:
Correlates of load carriage and obstacle course performance among
women. Work 2002; 18: 179-89,
7, Cotter JD, Roberts WS, Amos D, Lau W, Prigg SK: Soldier Performance
and Heat Strain During Evaluation of a Combat Fitness Assessment in
Northern Australia, DSTO-TR-1023, Melbourne, Victoria, Defence
Science and Technology Organisation, 2000,
8, Patterson MJ, Roberts WS, Lau W, Marsden JF, Prigg SK: Gender
and Physical Training Effects on Soldier Physical Competencies and
Physiological Strain, DSTO-TR-1875, Melbourne, Victoria, Defence
Science and Technology O rganisation, 2005,
9, Jette M, Kimick A, Sidney K: Evaluation of an indoor standardized
obstacle course for Canadian infantry personnel. Can J Sport Sei 1990;
15:59-64,
10, Bishop PA, Fielitz LR, Crowder TA, Anderson CL, Smith JH, Derrick
KR: Physiological determinants of performance on an indoor military
obstacle course test. Mil Med 1999; 164: 891-6 ,
11,
Gore CJ (editor): Physiological Tests for Elite Athletes, p 465, Lower
Mitcham, South Australia, Human Kinetics, 2000,
12, Laing AK, Billing DC, Ham DJ, Attwells RL, Patterson MJ, Fogarty
AL: Comparison of occupationally specific physical employm ent assess-
ments (PEAs) and generic military fitness tests, Med Sei Sports Exerc
2008;
40: S47,
13, Harman EA, Gutekunst D J, Frykman PN, et al: Prediction of simulated
battlefield physical performance from field-expedient tests. Mil Med
2008; 173:36-41 ,
14, Richmond VL, Rayson MP, Wilkinson DM, et al: Development of an
operational fitness test for the Royal Air Force, Ergonomics 2008;
5
:
9 3 5 ^ 6 ,
15,
Martin PE, Nelson RC: The effect of carried loads on the combat-
ive movement performance of men and women. Mil Med 1985; 150:
357-62,
16,
Billaut F, Bishop D: Muscle fatigue in males and témales during
multiple-sprint exercise. Sports Med 2009; 39: 257-78,
17, Knapik J, Bahrke M, Staab J, Vogel J, O'Conno r J Frequency of Loaded
Road March Training and Performance on a Loaded Road March,
T13-90, Natick, MA, US Army Research Institute of Environmental
Medicine, 1990,
18,
Kraemer WJ, Vogel JA, Patton JF, Dziados JE, Reynolds KL: The
Effects of Various Physical Training Programs on Short Duration, High
Intensity Load Bearing Performance and the Army Physical Fitness Test,
Technical Report 30/87, Natick, MA, US Army Research Institute of
Environmental Medicine, 1987,
19, Medb0 Jl, Burgers S: Effect of training on the anaerobic capacity, Med
Sei Sports Exerc 1990; 22: 501-7,
20 , Tabata I, Nishimura K, Kouzaki M, et al: Effects of moderate-intensity
endurance and high-intensity intermittent training on anaerobic capacity
and VOjmax, Med Sei Sports Exerc 1996; 28: 1327-30,
21 ,
Birrel SA, Haslam RA : The influence of rifle carriage on the kinetics of
human gait. Ergonomics 2008;
51:
816-26,
![Page 6: Document (5)](https://reader031.vdocuments.mx/reader031/viewer/2022020812/563db8e9550346aa9a982989/html5/thumbnails/6.jpg)
7/17/2019 Document (5)
http://slidepdf.com/reader/full/document-5-568e0f0846ef7 6/6
Copyright of Military Medicine is the property of Association of Military Surgeons of the United States and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.