Feature Protecting the Protectors Tactical athletes—firefighters, law enforcement officers, and military personnel—make it their mission to keep Americans safe. Across the country, PTs are committed to returning the favor. By Eric Ries | May 2017 CDR Leslie Hair, PT, DSc, assists a sailor with dynamic core exercise. (US Navy photo by Naval Hospital Jacksonville/Released) At APTA's Combined Sections Meeting (CSM) in San Antonio in February, Jake Morrow, PT, MPT, briefed a packed ballroom of physical therapists (PTs), physical therapist assistants (PTAs), and students on the physical demands that firefighters face. It's a subject with which he's personally familiar. Although Morrow, for many years a PT in the US Army, remains an active clinician as an Army reservist, his day job—his night job, too, during 48-hour shifts—is fighting fires and accompanying emergency personnel on calls as a member of the Beverly Hills Fire Department in Southern California. Morrow, a board-certified specialist in both orthopaedic and clinical electrophysiologic physical therapy, needn't cite patient accounts or consult the literature to knowledgeably describe the conditions that cause firefighters to need physical therapy, or the ways PTs can safeguard them against potential injury and help safely return them to duty. He's literally been there—wearing 40 pounds of "turnouts" (protective clothing, from helmet to boots), carrying another 15 pounds of tools (pliers, rope, climbing equipment, wood chocks, and more), and lugging 60 pounds of firehose. He's optimized the awkward, laden gait he calls "the John Wayne walk." He's battled "nozzle reaction force" while aiming hoses at leaping flames and navigated through crumbling rooms at temperatures of 400 or more degrees Fahrenheit. He's labored, while doing so, to breathe through an apparatus that reduces that ability by 20%. Morrow, no stranger to intense physical demands from his days in military service, also played collegiate football for 4 years. Still, he says, "Nothing I've ever done compares to the fatigue I've experienced in 20 minutes of firefighting." MAJ Richard Westrick, PT, DPT, DSc, notes, however, that "the load carriage and equipment-lifting requirements for military personnel aren't dissimilar to those for firefighters." Military personnel, too, he notes, operate in extreme environments—"from underwater Navy SEALS and Army Special Forces dive teams to military freefall operations and the challenges of working in the mountains of Afghanistan. We ask soldiers to wear a full combat fighting load that can weigh 120 pounds and to 'ruck march' over uneven terrain for distances of 12 or more miles." Westrick, who has known Morrow since the latter's active-duty Army days, is chief deputy of the Military Performance Division at the US Army Research Institute of Environmental Medicine (USARIEM) in Natick, Massachusetts. He is a board-certified specialist in both orthopaedic and sports physical therapy. Another former Army colleague of Westrick's is Kyle Sela, PT, DPT, who coordinates the sports medicine program and is a clinic manager at St Luke's Health System in Boise, Idaho. Sela is "passionate," he says, about treating law enforcement officers, even though they constitute only a small portion of his patient population, because of the service they provide to society and the unique challenges they face in their work. The job of a law enforcement officer requires physicality, but the logistics are counterproductive to that. An officer on patrol typically spends 50% of his or her time sitting in a vehicle, Sela notes, yet may at any moment be called upon to sprint into pursuit and apprehend a suspect who may be armed with a gun or other weapon. Add the fact that the officer is wearing a fully equipped duty belt (sidearm, handcuffs, and more) and a bullet-proof vest that altogether typically weigh more than 16 pounds. Factor in the persistent threat of danger, the psychological effects of isolation—there's no firehouse or barracks full of buddies with whom to blow off steam after traumatic events—and unhealthy habits such as overeating that law enforcement officers often employ to combat stress. "There's this unfortunate stereotype of the overweight cop, but it's frankly a very difficult job in which to stay fit," says Sela, a board-certified specialist in orthopaedic and sports physical therapy and a certified strength and conditioning specialist. "At the same time, however, there are very few occupations in which fitness is more important—for the officer's sake and the public's." Westrick and Sela joined Morrow on that stage in San Antonio, along with LTC Michael Garrison, PT, DSc, chief of physical therapy at Darnall Army Medical Center at Fort Hood in Texas. For the second straight CSM, Westrick, Morrow, and Sela gave a full house an overview of the ways in which the physical therapy profession can best serve firefighters, law enforcement officers, and military personnel. As was the case at CSM a year earlier, those occupations were grouped under the same umbrella term. The title of the 2017 presentation was "Fire, Police, and Military Tactical Athletes: Here It's Not a Game!" What exactly, then, is a "tactical athlete"? MAJ Joseph Kardouni, PT, DPT, PhD, coauthored a paper 2 years ago in the Strength and Conditioning Journal that began, "The term 'tactical athlete' commonly is used by those in the strength and conditioning community to identify personnel in law enforcement, military, and rescue professions who require unique physical training strategies aimed at optimizing occupational physical performance." (Kardouni directs USARIEM's Total Army Injury and Health Outcomes Database team. For a link to the full document, see the resources box on page 25.) Kristen Wilburn, PT, DPT, a Savannah, Georgia-based research fellow for USARIEM, puts it in these terms. "To me," she says, "a tactical athlete is a person who routinely performs physically demanding and athletic tasks as part of his or her occupation, with location and objective being the big differences from what traditional athletes do. Tactical athletes don't operate in controlled environments," she notes, "and the consequences of their actions tend to be considerably more serious than just winning a competition." Wilburn is a board-certified specialist in sports physical therapy. A Growing Interest Danny McMillian, PT, DSc, is a clinical associate professor in the physical therapy department at the University of Puget Sound in Tacoma, Washington, and a former Army PT who has offered DPT students clinical experiences at a nearby Army base so they can see tactical athletes in action. He gave a presentation at CSM in 2011 titled "Building and Sustaining the Tactical Athlete: A New Role for the Physical Therapist." Ask him now if that role remains "new," and he responds that it's quickly evolving. "It's definitely more established now," says McMillian, a board-certified specialist in orthopaedic physical therapy and a certified strength and conditioning specialist. He cites the practice of embedding PTs in military units—which had begun before his 2011 presentation but now constitutes a "changed dynamic"—and observes that "more civilian PTs nowadays are marketing their services to firefighters, police departments, first responders, and the military." Another big change since McMillian's CSM appearance 6 years ago was the introduction in 2015 of the APTA Sports Physical Therapy Section's Tactical Athletes Special Interest Group (SIG), which Westrick chairs. "There had been growing interest for several years among Sports Section members in establishing a subgroup that would focus specifically on the needs of this population," Westrick recounts. "When I was asked if I'd be interested in founding a SIG, I immediately said yes. Given my military background and the fact that I have nearly a dozen close friends and/or colleagues who are firefighters or law enforcement personnel, I jumped at the opportunity." (For more on the SIG's goals and activities, see "A SIGnificant Step" on page 20.) "I'm deeply committed to seeing that tactical athletes get the attention and care they deserve," Westrick says. "Look at all the things they do for us as a society. I think we owe it to them to help them avoid injury if possible and to facilitate their return to work as quickly but safely as is feasible when they are injured." The PTs who serve this population face challenges, however, ranging from issues of self-identity to still-evolving research on subpopulation-specific best practices. A Holistic Outlook The first step to helping tactical athletes prepare themselves for the physical and mental demands they face, Westrick says, is securing their buy-in to a "holistic approach" centered on the "performance triad"—an Army term encompassing the elements of activity, sleep, and nutrition. In a nutshell, "Tactical athletes need to take better care of themselves." But here's a problem from the get-go: Too often, Westrick says, the oft-sedentary police officer, the firefighter plodding along in heavy gear, and the young military recruit who's just arrived at basic training and is highly susceptible to injury from high-intensity activity simply don't see themselves as "athletes." Morrow agrees, adding, "As a result, many of them don't train or prepare themselves properly. They don't understand or appreciate that holistic approach. They haven't learned that safe-exercise 'bang for the buck' that PTs bring to the table." The importance of this population accepting and internalizing the "athlete" tag cannot be overstated, in McMillian's view. And he believes PTs can play an important role in instilling that message. "As with professional athletes in sports, the physicality of tactical athletes is a huge part of their occupational value," he observes. "PTs can and should educate tactical athletes on the best practices of athletes in traditional sports and how those might apply in tactical settings. Many tactical athletes have never made that connection. It's vitally important, though," McMillian says, "that they understand that peak performance requires a smart, disciplined approach to maintaining body and mind." The most common injuries that hinder peak performance in tactical athletes aren't dissimilar to those that afflict traditional athletes, the PTs interviewed for this article say. The most vulnerable areas are the back, neck, shoulders, and lower extremities. "Overuse injuries happen a lot," says CDR Leslie Hair, PT, DSc, associate director for clinical support services at Naval Hospital Jacksonville in Florida. "Sprains and strains happen a lot. Of course, when you're running around with a lot of extra weight from your protective gear, that's going to affect how you move and throw off your center of balance. We as PTs need to account for that in effectively 'prehabbing' this population and [in case of injury] safely returning them to action." "We use best evidence and best practice to identify appropriate and optimal injury-prevention programs for these athletes," says Kardouni, a board-certified specialist in both orthopaedic and sports physical therapy. He concedes, however, "We still have some work to do when it comes to developing, comparing, and contrasting injury profiles between tactical and traditional athletes, and also among the tactical professions." "There's definitely a need to move the research forward," Westrick agrees, while noting that USARIEM is active on that front on the military side. "We have researchers looking at everything from basic science—such as ways to exploit the inflammatory process to facilitate healing—to quantifying the physical demands associated with specific military jobs and projects, and developing military-specific decision-making aids," Westrick says. "But 1 thing I'd really like to see in terms of research," he adds, "is improved collaborative efforts among PTs who work with the various types of tactical athletes. There are opportunities to further our understanding of musculoskeletal injury in firefighters, for example, and those findings might inform certain aspects of military requirements and training." "I'm seeing more and more research and studies come out," Westrick says, citing in particular the work of the National Strength and Conditioning Association (NSCA), which has developed a Tactical Strength and Conditioning (TSAC) program, and research on law enforcement and firefighter populations out of Bond University in Australia (see the resources box on page 25). Still, much more data is needed, he says—noting that in firefighting alone, there are significant differences between the challenges and needs of urban firefighters and those of men and women who battle wildfires. "There still is not a great deal of peer-reviewed research on best practice in law enforcement," Sela adds. "In relation to the military and firefighters, it's vastly understudied and not very well-understood in the medical literature. The research community needs to step up its game so that PTs can make better-informed decisions when it comes to injury-prevention and mitigation of long-term disability in law enforcement officers." "I'm not sure we've found the silver bullet for injury prevention for tactical athletes," Wilburn agrees, while noting that USARIEM is "working on developing a military-specific lower-quarter functional scale or outcome measure to aid in return-to-duty decision-making." But that's not to say that PTs across the tactical athlete spectrum aren't already making significant positive differences in the lives of those they serve, by reducing the chance of injury and safely returning tactical athletes to duty. From 2012 to 2016, Hair treated Naval Special Warfare tactical athletes. "We worked closely with strength and conditioning coaches, registered dietitians, and sports psychologists to screen these athletes for potential injury and give them corrective exercises that helped prevent those injuries," he says. While reiterating that he earns his paycheck as a firefighter, Morrow often shares his physical therapy expertise to advise his peers on proper positioning and lifting techniques to avoid injury. He's also designing a departmental wellness program that will include annual medical screens, biannual fitness tests, optional 1-on-1 fitness training, and classes on such subjects as proper exercise technique and optimal dietary and sleep habits. Morrow notes that some larger cities have created or are developing wellness programs for their firefighters—Los Angeles and Denver among them. He supports the trend. "We want these tactical athletes to feel strong and confident in what they're doing, and to know what to do to prevent getting hurt," he says. Morrow would like to see his fire department's wellness program expanded to Beverly Hills's police personnel. One thing Sela tries to instill in law enforcement officers is "active sitting," which he describes as "putting the body into a position that requires concentration and muscle activation, as opposed to simply letting gravity take over." Law enforcement officers, he says, "should periodically take their body through small arranged motions, or do isometric contractions to force blood flow to the larger muscle groups. It's a way to stay actively ready throughout the day." "If you look at the way a lot of people train—guys in particular—there's more of a bodybuilder mentality," Sela notes, "that emphasizes muscle hypertrophy and looking strong" Sela says. "But athletes, whether traditional or tactical, train to be both strong and powerful—to move forcefully and with purpose. The bodybuilder approach really doesn't prepare a law enforcement officer to tackle and apprehend a suspect—to truly be a tactical athlete. Education," he says, "can go a long way in getting these individuals into a fitness program that will help them in the long term." McMillian concedes that the functional movement screen (FMS)—a ranking and grading system that documents movement patterns to identify functional limitations and asymmetries—is imprecise and fails to account for dissimilarities among athlete groups. Nevertheless, he says, it helps PTs serve tactical athletes in 2 important ways. "First, you're identifying the performers who most need your resources as a PT," McMillian says. "Second, it gets these tactical athletes thinking about the quality of their movement—as opposed to how much weight they can lift or how fast they can run. It's a different concept, and their ears tend to perk up. They may even compare their FMS scores with those of their buddies—get competitive about it. So, sort of through the back door, you've gotten them thinking in a different and beneficial way." This touches on something that all the PTs interviewed for this article emphasize: the importance of PTs intensely listening to tactical athletes, asking them many questions, and trying, to the greatest extent possible, to understand their mindset. "PTs need to appreciate the culture of tactical athletes—the psychosocial aspects of their care," McMillian says. "While that's true of PTs with any patient population, I think it's a heightened dynamic with this particular one. Tactical athletes in some ways are unique in what's demanded of them, and that shapes their thinking." He gives this example: "Skipping as part of a dynamic warm-up is well-accepted in sports such as soccer, but when I introduced it to soldiers, a significant number of them felt awkward doing it or questioned its utility. What I learned was that their negative assessment of it outweighed the possible benefit. So, I substituted something else." Growth Potential Appreciation of the culture is high on the list of qualities and skills that serve PTs well in working with tactical athletes, say the PTs who spoke with PT in Motion. Others include strong manual therapy skills, a good understanding of strength and conditioning principles, and willingness to consider and perfect interventions and techniques at which they may be unpracticed. On the last score, "Be open-minded," counsels Hair, a board-certified specialist in orthopaedic physical therapy and a fellow of the American Academy of Orthopaedic Manual Therapists. "Dry needling, for example, was an intervention that I used a lot with tactical athletes. I also sometimes used the Graston technique [of instrument-assisted soft tissue mobilization]. A lot of my patients didn't have a lot of time," he says. "I sometimes needed to do things that quickly addressed their pain issues and sent them safely back to their jobs." Any PT who is contemplating working with tactical athletes should witness them in action, Kardouni says. "That doesn't mean you have to be there for every law enforcement or firefighting exercise," he elaborates. "But, taking the opportunity to see what they see and do, and what is required of them, is highly instructive. It will make you more insightful in tailoring your offerings to their needs." McMillian echoes the recommendation. "Invite yourself over to the local police or fire department. Share the existing evidence about the benefits of a proactive approach to safe training practices. Let them know that you can help prevent injuries, address those that do occur, and help improve the health of personnel in the longer term." "There are often opportunities to go on ride-alongs with law enforcement or attend events at the local firehouse," Wilburn notes. "Networking with tactical athletes in these ways is a great first step." Beyond that, Wilburn, a member and enthusiastic advocate of the Tactical Athletes SIG, encourages PTs to join the SIG for its various resources and networking opportunities. She also urges her PT colleagues to attend pertinent Sports Section-sponsored events at APTA conferences and meetings. In San Antonio earlier this year, she notes, "Here It's Not a Game!" was preceded by an all-day preconference session on tactical strength and conditioning that featured a strength coach from the NSCA's TSAC program. Westrick urges interested PTs to check out the SIG's website and follow it on social media. He also welcomes direct inquiries. Kardouni sees the tactical athlete population as potentially a "huge area of growth" for the physical therapy profession. "Most tactical organizations have plans and personnel in place to provide urgent and emergent care for injuries incurred in the line of duty, but they're not necessarily prepared for optimal management of nonemergent injuries," he says. "Musculoskeletal issues fall firmly in that category, creating an ideal niche for direct-access PTs to fill—the health-maintenance aspect of things." The opportunities are there for PTs who do their homework, Sela agrees. "If you can compile data on a police or fire department's medical and insurance costs and tell them how much money you can save them through injury prevention and other benefits of your expertise, you might just talk your way into a job," he says. "PTs in areas with large populations of National Guard or military reservists," Wilburn adds, "could tailor their services to those tactical athletes, who typically are not seen and treated by active-duty military PTs." Addictive Rewards Any PT who starts working with tactical athletes is likely to get hooked, Kardouni says. "Seeing the conditions under which these folks work, then helping them recover from injury, improve their job performance, and enhance their quality of life, holds rewards that go beyond even the typical therapist-patient relationship," he says. "These are people who are serving the public and our nation. When you help them, you're helping so many other people who benefit from their service. It's incredibly rewarding." "These individuals live and breathe their profession," Sela says. "They didn't go into it because there was a job opening. When they're sidelined, it can be devastating to them. It feels incredible to play a key role in returning them to duty." "I think back on my time with the Special Forces," Westrick says, "working with tactical athletes from their first physical therapy visit through surgery and rehab, helping them get back to the highest level of performance. It's so motivating for a physical therapist. Not all of those tactical athletes remember me, but I won't ever forget a single one of them." Eric Ries is the associate editor of PT in Motion. A SIGnificant StepThe goal of the APTA Sports Physical Therapy Section's Tactical Athletes Special Interest (SIG) is, per the description on its website, "to support and expand the knowledge and understanding of Sports Physical Therapy members working with tactical athlete communities." It's meant to "facilitate collaboration and communication between researchers, clinicians, and tactical athletes regarding various aspects of training, injury prevention, performance, and physical therapy unique to this population.""I'd like to see it become the resource for physical therapists when it comes to these athletes," says MAJ Richard Westrick, PT, DPT, PhD, DSc, the SIG's chair since its inception in mid-2015.The numbers so far suggest it's making inroads. As of February, its membership stood at 120, while its Facebook and Twitter followers numbered more than 500 and 400, respectively.The SIG is a place where PTs, PTAs, and students can come—some of its resources are open-access—to ask questions, share information, catch up on the latest research, and perhaps even find a job. There are discussion threads for research, employment, and clinical opportunities for students. Once a member survey of "hot topics" in the field has been completed and analyzed later this year, additional SIG priorities no doubt will be identified, says Westrick, who is deputy chief of the military performance division at the US Army Research Institute of Environmental Medicine (USARIEM) in Natick, Massachusetts.SIG member Kristen Wilburn, PT, DPT, a research fellow whose work supports USARIEM's military performance efforts, is among the SIG's most spirited supporters. She avidly follows its social media postings and shares them with colleagues."I'd like to see the Tactical Athletes SIG continue to grow as a platform for collaboration and research among those who serve this unique population," she says. "There are a lot of bright, passionate physical therapists out there working with tactical athletes and doing great things. By using the SIG to share and systematically study the clinical research, we can continue to build a solid body, become more cutting-edge as professionals, identify differences among subpopulations, and, ultimately, better serve tactical athletes."It Started With Combined Sections MeetingKyle Sela, PT, DPT, didn't know what to expect when he agreed to participate in a tactical athlete-themed symposium at APTA's Combined Sections Meeting (CSM) in February 2016. At that point the APTA Sports Section's Tactical Athlete Special Interest Group, which had organized the event, was less than a year old.Would the attendance watchword be "buzz" or "bust"? Beyond that, would the gathering produce any tangible results?The answers, as it turned out, were "buzz" and "yes." Not only did more than 400 PTs, PTAs, and students pack the ballroom that winter day in Anaheim, California, but 1 audience member would spearhead the creation of a police-training performance center in Sela's backyard.Attending the symposium was Bailey Vail, then a second-year student in the doctor of physical therapy (DPT) program at Idaho State University (ISU). She felt that the physical training and health/wellness education her husband and other recruits had received at their police officer standards and training (POST) academy had been inadequate. Sela and the other symposium speakers enlightened her on the ways PTs can help law enforcement officers and other tactical athletes reduce their injury potential by tailoring care to their specific challenges and needs. Vail felt energized to take matters into her own hands.With the strong support and assistance of ISU physical therapy faculty members Derek Gerber, PT, DPT, and Alex Urfer, PT, PhD, Vail established the Center for Tactical Performance (CTAP) at ISU to work with the state-certified POST academy already based at the school to study and develop safer and more effective ways to train police officers and promote their long-term health."ISU DPT students first participated in education and training of the cadet class last fall," Vail recounts. "CTAP now is in its second semester working with the academy. The school treats CTAP as it does any other practicum experience. Each semester, as many as 3 second- or third-year DPT students are assigned to work with the academy and are given school credit and a grade for their participation."The long-term hope is that police recruits will reap great rewards."CTAP has many goals and objectives," Vail says. "First, we're collecting data to get a better picture of what the 'typical' police academy cadet looks like, in terms of such factors as sex, age, health and fitness, comorbidities, and prior experience in tactical professions. The answers to those questions will facilitate development of physical training that best fits the population.""Also," she continues, "we're attempting to decrease the number of overuse injuries experienced in a typical boot camp or academy setting. We're doing this by monitoring and assessing form and technique during performance of common exercises. We're also attempting to make physical training for these athletes more specific to their job requirements."Current testing standards for cadets, she notes, "haven't changed in many years, and still focus on sit-ups, push-ups, and running. But those things don't really help anyone understand how fit an officer is to perform his or her duties," she says. "To address that disconnect, we're integrating other components of their training, such as arrest tactics, into their physical fitness sessions."By being on the scene at the academy, PT-supervised DPT students "can assess and treat injuries, as needed. If cadets get injured," Vail notes, "we can modify their workouts so they can continue working toward their fitness goals."Other elements of CTAP focus on health and wellness education, emphasizing the importance of lifelong fitness and the keys to remaining healthy throughout a career in law enforcement. "The aim," Vail says, "is to provide cadets with information they can apply to their everyday life—such as what a healthy diet looks like, how to design a whole-body workout, how to cultivate optimal sleep habits, and awareness of the diseases to which their line of work makes them most susceptible."While emphasizing that CTAP is a fledgling effort that hasn't yet incorporated such anticipated elements as VO2 max exercise testing, electrocardiograms, and collaboration with other health professionals such as registered dietitians, Vail has a grand vision."We're hoping that CTAP will develop over time into a model for other POST academies throughout the state of Idaho, and potentially nationwide," she says.Vail will be there to witness the program's development beyond graduation this month. She's staying on at ISU to earn a master's degree in athletic training and will continue to develop and participate with CTAP through the DPT program for the next 2 years."It's interesting the way everything came together, starting with our presentation at CSM last year," Sela observes. In fact, he hosted Vail over the winter. She completed her penultimate clinical rotation at St Luke's Health System in Boise, where Sela is sports program coordinator and a clinical manager."Clearly," he says, "that symposium fired her up."ResourcesWebsitesSports Physical Therapy Section Tactical Athletes Special Interest Grouphttps://spts.org/member-benefits-detail/enjoy-member-benefits/special-interest-groups/tactical-athlete-sigNational Strength and Conditioning Association's Tactical Strength and Conditioning Programwww.nsca.com/tsac-professionals/Journal of Athletic Training Tactical Athlete Special Issue (November 2016)http://natajournals.org/toc/attr/51/11Personal Research Page of Rob Orr, Bond University (Australia)https://works.bepress.com/rob_orr/Video"Optimizing Soldier Performance at the U.S. Army Research Institute of Environmental Medicine," narrated by MAJ Richard Westrick, PT, DPT, PhD, DScwww.youtube.com/watch?v=h2qs5Xxr95o&feature=youtu.beSelected ResearchScofield DE, Kardouni JR. The tactical athlete: a product of 21st century strength and conditioning. Strength Cond J. 2015;37(4):2-7.Rhea M. Needs analysis and program design for police officers. Strength Cond J. 2015;37(4)30-34.Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness of neuromuscular warmup strategies that require no additional equipment for preventing lower limb injuries during sports participation: a systematic review. BMC Medicine. 2012;10:75.Morton RW, Oikawa SY, Wavell CG, et al. Neither load for systemic hormones determine resistance training-mediated hypertrophy or strength gains in resistance-trained young men. J Appl Physiol. 2016;121(1):129-138.