Amir Hadid

Variation in tibial functionality and fracture susceptibility among healthy, young adults arises from the acquisition of biologically distinct sets of traits.

Physiological systems like bone respond to many genetic and environmental factors by adjusting traits in a highly coordinated, compensatory manner to establish organ‐level function. To be mechanically functional, a bone should be sufficiently stiff and strong to support physiological loads. Factors impairing this process are expected to compromise strength and increase fracture risk. We tested the hypotheses that individuals with reduced stiffness relative to body size will show an increased risk of fracturing and that reduced strength arises from the acquisition of biologically distinct sets of traits (ie, different combinations of morphological and tissue‐level mechanical properties). We assessed tibial functionality retrospectively for 336 young adult women and men engaged in military training, and calculated robustness (total area/bone length), cortical area (Ct.Ar), and tissue‐mineral density (TMD). These three traits explained 69% to 72% of the variation in tibial stiffness (p < 0.0001). Having reduced stiffness relative to body size (body weight × bone length) was associated with odds ratios of 1.5 (95% confidence interval [CI], 0.5–4.3) and 7.0 (95% CI, 2.0–25.1) for women and men, respectively, for developing a stress fracture based on radiography and scintigraphy. K‐means cluster analysis was used to segregate men and women into subgroups based on robustness, Ct.Ar, and TMD adjusted for body size. Stiffness varied 37% to 42% among the clusters (p < 0.0001, ANOVA). For men, 78% of stress fracture cases segregated to three clusters (p < 0.03, chi‐square). Clusters showing reduced function exhibited either slender tibias with the expected Ct.Ar and TMD relative to body size and robustness (ie, well‐adapted bones) or robust tibias with reduced residuals for Ct.Ar or TMD relative to body size and robustness (ie, poorly adapted bones). Thus, we show there are multiple biomechanical and thus biological pathways leading to reduced function and increased fracture risk. Our results have important implications for developing personalized preventative diagnostics and treatments.

Modeling mechanical strains and stresses in soft tissues of the shoulder during load carriage based on load-bearing open MRI

Shoulder strain is a major limiting factor associated with load carriage. Despite advances in backpack designs, there are still reports of shoulder discomfort, loss of sensorimotor functions, and brachial plexus syndrome. The current study is aimed at characterizing mechanical loading conditions (strains and stresses) that develop within the shoulders soft tissues when carrying a backpack. Open MRI scans were used for reconstructing a three-dimensional geometrical model of an unloaded shoulder and for measuring the soft tissue deformations caused by a 25-kg backpack; subsequently, a subject-specific finite element (FE) model for nonlinear, large-deformation stress-strain analyses was developed. Skin pressure distributions under the backpack strap were used as reference data and for verifying the numerical solutions. The parameters of the model were adjusted to fit the calculated tissue deformations to those obtained by MRI. The MRI scans revealed significant compression of the soft tissues of the shoulder, with substantial deformations in the area of the subclavian muscle and the brachial plexus. The maximal pressure values exerted by a 25-kg load were substantial and reached ∼90 kPa. In the muscle surrounding the brachial plexus, the model predicted maximal compressive strain of 0.14 and maximal tensile strain of 0.13, which might be injurious for the underlying neural tissue. In conclusion, the FE model provided some insights regarding the potential mechanisms underlying brachial plexus injuries related to load carriage. The large tissue deformations and pressure hotspots that were observed are likely to result in tissue damage, which may hamper neural function if sustained for long time exposures.

Sweat Rate Prediction Equations for Outdoor Exercise with Transient Solar Radiation

We investigated the validity of employing a fuzzy piecewise prediction equation (PW) [Gonzalez et al. J Appl Physiol 107: 379-388, 2009] defined by sweat rate (m(sw), g·m(-2)·h(-1)) = 147 + 1.527·(E(req)) - 0.87·(E(max)), which integrates evaporation required (E(req)) and the maximum evaporative capacity of the environment (E(max)). Heat exchange and physiological responses were determined throughout the trials. Environmental conditions were ambient temperature (T(a)) = 16-26°C, relative humidity (RH) = 51-55%, and wind speed (V) = 0.5-1.5 m/s. Volunteers wore military fatigues [clothing evaporative potential (i(m)/clo) = 0.33] and carried loads (15-31 kg) while marching 14-37 km over variable terrains either at night (N = 77, trials 1-5) or night with increasing daylight (N = 33, trials 6 and 7). PW was modified (Pw,sol) for transient solar radiation (R(sol), W) determined from measured solar loads and verified in trials 6 and 7. PW provided a valid m(sw) prediction during night trials (1-5) matching previous laboratory values and verified by bootstrap correlation (r(bs) of 0.81, SE ± 0.014, SEE = ± 69.2 g·m(-2)·h(-1)). For trials 6 and 7, E(req) and E(max) components included R(sol) applying a modified equation Pw,sol, in which m(sw) = 147 + 1.527·(E(req,sol)) - 0.87·(E(max)). Linear prediction of m(sw) = 0.72·Pw,sol + 135 (N = 33) was validated (R(2) = 0.92; SEE = ±33.8 g·m(-2)·h(-1)) with PW β-coefficients unaltered during field marches between 16°C and 26°C T(a) for m(sw) ≤ 700 g·m(-2)·h(-1). PW was additionally derived for cool laboratory/night conditions (T(a) < 20°C) in which E(req) is low but E(max) is high, as: PW,cool (g·m(-2)·h(-1)) = 350 + 1.527·E(req) - 0.87·E(max). These sweat prediction equations allow valid tools for civilian, sports, and military medicine communities to predict water needs during a variety of heat stress/exercise conditions.

Prediction model for attrition from a combat unit training program.

Moran, DS, Evans, RK, Arbel, Y, Hadid, A, Laor, A, and Fuks, Y. Prediction model for attrition from a combat unit training program. J Strength Cond Res 25(11): 2963–2970, 2011—The purpose of this study was to develop a prediction model for the attrition rate of soldiers from an 8-month advanced military training program based on physical and psychological factors. Two groups of 59 and 61 healthy, fit young men (18.7 ± 0.7 years) entering a rigorous combat unit training program in the Israeli Defense Forces were recruited to participate in this study. Data on anthropometrics, nutrition, blood measures (chemical and hematological), fitness, and bone quality were collected on the induction day. Psychological questionnaires were completed at 3 time points: baseline—upon entry to basic training (BT), after 2 months, and after 4 months (completion of BT). The data of the 2 groups were pooled together for the analysis and to construct a new prediction model for attrition (Patt) as follows: Patt = 11.20 − 0.87EstCom4 − 0.72Sc − 0.23%BF; where EstCom4 is commander appreciation as perceived by the soldier after 4-month BT, Sc is a self-confidence grade, and %BF is the % body fat. The new suggested model successfully predicted 75.3% of subject attrition in the combat unit. We therefore concluded that Special Forces recruits with relatively low body fat percentage (%BF), low self-esteem, and who feel unappreciated by their commander are at a higher dropout risk from a rigorous combat training program.

The effect of mechanical strains in soft tissues of the shoulder during load carriage.

Soldiers and recreational backpackers are often required to carry heavy loads during military operations or hiking. Shoulder strain appears to be one of the limiting factors of load carriage due to skin and underlying soft tissue deformations, trapped nerves, or obstruction of blood vessels. The present study was aimed to determine relationships between backpack weights and the state of loads in the shoulder׳s inner tissues, with a special focus on the deformations in the brachial plexus. Open-MRI scans were used for developing and then verifying a three-dimensional, non-linear, large deformation, finite element model of the shoulder. Loads were applied at the strap-shoulder contact surfaces of the model by pulling the strap towards the shoulder until the desired load was reached. Increasing the strap tensile forces up to a load that represents 35kg backpack resulted in gradual increase in strains within the underlying soft tissues: the maximal tensile strain in the brachial plexus for a 25kg backpack was 12%, and while carrying 35kg, the maximal tensile strain increased to 16%. The lateral aspect of the brachial plexus was found to be more vulnerable to deformation-inflicted effects than the medial aspect. This is due to the anatomy of the clavicle that poorly shields the plexus from compressive loads applied during load carriage, while the neural tissue in the medial aspect of the shoulder is better protected by the clavicle. The newly developed model can serve as a tool to estimate soft tissue deformations in the brachial plexus for heavy backpack loads, up to 35kg. This method will allow further development of new strap structures and materials for alleviating the strains applied on the shoulder soft tissues.

Effect of Load Carriage on Upper Limb Performance

Carrying heavy backpacks are often associated with shoulder discomfort or pain, loss of sensorimotor functions, and brachial plexus injuries that might hamper performance. On the basis of previous research, the cause of these symptoms could be tissue deformations of the brachial plexus and the subclavian artery caused by the shoulder straps. Purpose This study aimed to evaluate the changes in the upper extremity hemodynamic and neural function and to assess how they are associated with brachial plexus tissue deformation during heavy load carriage. Methods Ten young healthy adults carried for 45 min a backpack load (40% of their body weight) while standing freely, followed by 15 min of recovery (unloaded). Index-finger microvascular flow and sensorimotor function were measured before and after carrying the load, and after recovery. The following sensorimotor functions were measured: light touch thresholds by the index finger and little finger, forearm thermal sensation thresholds, and gross motor function. In addition, marksmanship accuracy, as an indication for fine motor function, was tested. Results Load carriage resulted in an average decrease of ~40% in microvascular flow and a significant decrement in light touch sensation (P < 0.05), but not in thermal sensation and gross motor functions. An increase in the light touch threshold was highly correlated with a reduced index-finger microvascular blood flow (r = 0.79, P = 0.007). These physiological effects were associated with a functional 34% decrement in the accuracy of target acquisition. Conclusion Heavy load carriage resulted in impaired light touch sensitivity and fine motor function, which were associated with reduced finger microvascular blood flow.

Tibial Stress Changes in New Combat Recruits for Special Forces: Patterns and Timing at MR Imaging

PURPOSE To characterize the incidence, location, grade, and patterns of magnetic resonance (MR) imaging findings in the tibia in asymptomatic recruits before and after 4-month basic training and to investigate whether MR imaging parameters correlated with pretraining activity levels or with future symptomatic injury. MATERIALS AND METHODS This study was approved by three institutional review boards and was conducted in compliance with HIPAA requirements. Volunteers were included in the study after they signed informed consent forms. MR imaging of the tibia of 55 men entering the Israeli Special Forces was performed on recruitment day and after basic training. Ten recruits who did not perform vigorous self-training prior to and during service served as control subjects. MR imaging studies in all recruits were evaluated for presence, type, length, and location of bone stress changes in the tibia. Anthropometric measurements and activity history data were collected. Relationships between bone stress changes, physical activity, and clinical findings and between lesion size and progression were analyzed. RESULTS Bone stress changes were seen in 35 of 55 recruits (in 26 recruits at time 0 and in nine recruits after basic training). Most bone stress changes consisted of endosteal marrow edema. Approximately 50% of bone stress changes occurred between the middle and distal thirds of the tibia. Lesion size at time 0 had significant correlation with progression. All endosteal findings smaller than 100 mm resolved or did not change, while most findings larger than 100 mm progressed. Of 10 control subjects, one had bone stress changes at time 0, and one had bone stress changes at 4 months. CONCLUSION Most tibial bone stress changes occurred before basic training, were usually endosteal, occurred between the middle and distal thirds of the tibia, were smaller than 100 mm, and did not progress. These findings are presumed to represent normal bone remodeling.

Effects of an improved biomechanical backpack strap design on load transfer to the shoulder soft tissues

The aim of the present study was to characterize shoulder strap structure and mechanical properties that may alleviate strains and stresses in the soft tissues of the shoulder. Utilizing a finite element model of the shoulder constructed from a single subject, we have quantified skin stresses exerted by backpack straps and the strains at the subclavian artery (SCA). For this end, standard shape straps with stiffness of 0.5, 1.2, and 5 MPa, were compared to the effects of optimized straps; a double-layered (soft outer layer and reinforced internal supporting layer) and newly-designed anatomically-shaped strap. Compared to the standard 0.5 MPa strap, the 5 MPa strap resulted in 4-times lower SCA strains and 2-times lower Trapezius stresses. The double-layered strap resulted in 40% and 50% reduction in SCA strains and skin stresses, respectively, with respect to the softer strap. The newly-designed anatomical strap exerted 4-times lower SCA strains and 50% lower skin stresses compared to the standard strap. This demonstrates a substantial improvement to the load carriage ergonomics when using a composite anatomical strap.

A Novel Model for the Optimization of Load Carriage Ergonomics

Soldiers, recreational backpackers, and students are often required to carry their own equipment using backpacks. Shoulder strain is one of the limiting factors of load carriage, due to higher sensitivity for pressure hot spots, and susceptibility to short-term injuries such as soft tissue damage and trapped nerves or obstruction of blood vessels. However, to date, no optimized system is available for heavy load carriage, and the considerations for schoolchildren and students are more fashion-weighted than ergonomics or comfort-weighted.

Deformations in the Shoulder Tissues During Load Carriage: A Computational Model.

Abstract Hadid, A, Belzer, N, Shabshin, N, Epstein, Y, and Gefen, A. Deformations in the shoulder tissues during load carriage: a computational model. J Strength Cond Res 29(11S): S144–S148, 2015—Shoulder soft tissue deformations seem to be one of the limiting factors of load carriage among soldiers and recreational backpackers that are required to carry heavy loads. Yet, there are no loading limits related to the forces borne by the shoulders, and the backpacks designs are not consistent with providing pressure relief from this sensitive anatomical region. The aim of this study was to develop a model that will enable to study the biomechanical loads that develop in the shoulder under heavy loads and to help in optimizing load carriage systems design. A 3-dimensional, anatomically accurate finite element model of a human shoulder was constructed based on MRI scans. The model was developed to calculate the effective stresses on the skin below the shoulder strap (superficial loads) and the effective strain in the brachial plexus region (inner tissue deformation) for loads of up to 35 kg. The model successfully predicted deformations in the soft tissue surrounding the brachial plexus when compared with deformations measured from load-bearing MRI scans. The model yielded a skin pressure mapping, which showed pressure hotspots in the clavicle region. Inner tissue deformations mapping, as assessed by brachial plexus envelop strains, were found to peak at 30% effective strain at the lateral aspect below the pectoralis muscle. The newly developed model successfully predicted soft tissue deformations in the shoulder related to backpacks. This model can be used to optimize load carriage systems for better distribution of pressure over the shoulders and lower inner tissue deformations.