MRI findings and physical performance as predictors of flight-induced musculoskeletal pain incidence among fighter pilots

Biomedical Human Kine ics, 9, 133–139, 2017 DOI: 10.1515/bhk-2017-0019 O iginal Pape MRI indings and physical pe o mance as p edic o s o ligh -induced musculoskele al pain incidence among igh e pilo s Ha i Rin ala1, Roope So elius2, Pi jo Rin ala3, Heini Huh ala4, Simo Sii onen5, Heikki Ky öläinen1,6 1 Uni e si y o Jy äskylä, Facul y o Spo and Heal h Sciences, Jy äskylä, Finland; 2 Cen e o Mili a y Medicine, Sa akun a Ai Command Heal h Clinic, Pi kkala, Finland; 3 Cen al Hospi al o Cen al Finland, Depa men o Physical Medicine and Rehabili a ion, Jy äskylä, Finland; 4 School o Public Heal h, Uni e si y o Tampe e; Resea ch Uni , Tampe e Uni e si y Hospi al, Tampe e, Finland; 5 De ence S a , Medical B anch, Helsinki, Finland; 6 Na ional De ence Uni e si y, Helsinki, Finland Summa y S udy aim: The aim o his s udy was o e alua e he possible associa ion o p e-ca ee magne ic esonance imaging (MRI) ind- ings and physical pe o mance le el wi h possible musculoskele al diso de s du ing je ligh aining. Ma e ial and me hods: The s udy g oup consis ed o 73 igh e pilo s who had unde gone p e-ca ee ce ical and lumba spine MRI. Physical pe o mance o a subg oup o he pilo s (n = 67) was measu ed ini ially a he same ime and ollowed up o he as je aining phase ( anging om 3.8 o 7.0 yea s). Musculoskele al pain his o y du ing pilo aining was aken om he medical cha s. MRI indings and physical pe o mance we e associa ed wi h pe cei ed clinical complain s du ing he ollow-up. Resul s: 82% o he ce ical and 92% o he lumba spines showed abno mali ies a a leas one disk le el. MRI did no e eal signi ican ce ical degene a ion. Thi een disk bulges in he lumba spine we e disco e ed, while 5 pilo s had lis hesis and/o os eophy e o ma ion on he spine (lumba e eb a 4/sac oiliac join le el, L4-SI). 41% o he s udied pilo s su e ed spinal symp oms du ing he ollow-up, bu only 16% and 17% o he ce ical and lumba MRI indings, espec i ely, we e associa ed wi h subsequen symp oms. Endu ance and s eng h le els we e no , bu lowe body mo o skills we e, s ongly ( ela i e isk, RR 0.46) associa ed wi h a dec eased numbe o ligh -induced medical appoin men s in he ea ly ligh ca ee . Conclusions: Mino MRI indings ha e no p edic able alue in he e y ea ly ligh ca ee . Ne e heless, e sa ile, skills/ powe -o ien ed exe cises be o e he ligh ca ee seem o be occupa ionally bene icial in educing musculoskele al diso de s. Keywo ds: MRI – Disk degene a ion – Ce ical spine – Lumba spine – Mili a y pilo – Fi ness In oduc ion Pilo s o mode n igh e s encoun e high +Gz o ces. The occupa ional wo k load may exceed he limi s o mus- cula pe o mance, hus causing musculoskele al pain and/ o disabili y in he daily se ice. Comba lying places high demands on bo h he pilo s’ spinal s uc u e and physical pe o mance. P ac ical me hods a emp ing o p edic pos- sible ligh -induced musculoskele al p oblems la e du ing he ligh ca ee include spinal column magne ic esonance imaging (MRI) and speci ic, occupa ionally o ien ed phys- ical i ness es ing du ing he pilo selec ion p ocess. Since a numbe o epo s indica e ha Gz exposu e has caused acu e in- ligh pain [15, 27] and inju ies [16, 21] as well as p ema u e degene a ion [13, 24], he heal h o spinal s uc u es should be assessed du ing selec ion o pi- lo s. The NATO Resea ch and Technology O ganiza ion has ecommended ha some o m o spinal diagnos ic im- aging should be included in he e alua ion o ec ui s in o de o de ec any spinal abno mali ies [8]. Findings wi h imaging echniques a e common among asymp oma ic young people, bu he e a e con adic o y epo s among pilo s. Among a selec ed popula ion o 232 No wegian mili a y pilo ec ui s, he spinal adiog aphs o only 1/3 o hem we e conside ed no mal, while 1/10 o ec ui s we e ejec ed om ligh aining due o a- diological indings [2]. A Ge man epo co e ing 10 922 asymp oma ic pilo ec ui s s a ed ha no mo e han 3% o hem we e “no mal”; i.e., hey had no mo phological changes in spinal X- ays [11]. In a g oup o young inex- pe ienced Swedish pilo s (a e age age 23 yea s, 220 ligh Au ho ’s add ess Ha i Rin ala, Uni e si y o Jy äskylä, P.O. Box 35, FI-40041 Uni e si y o Jy äskylä, Finland [email p o ec ed] B ough o you by | Tampe e Uni e si y Lib a y Au hen ica ed Download Da e | 12/4/17 10:37 AM H. Rin ala e al. 134 hou s), ce ical MRI showed a low equency o occu - ence o low-g ade degene a i e lesions [23]. A Finnish s udy showed ha he e we e no signi ican changes in pi- lo s’ spinal column du ing 13 yea s o ollow-up, bu only 12 pilo s we e ollowed [28]. Magne ic esonance scans a e mo e accu a e han con- en ional adiog aphs due o hei abili y o demons a e al- so in e e eb al disk pa hology. O he imaging echniques such as adiog aphy, myelog aphy and compu ed omog a- phy (CT) may p o ide complemen a y in o ma ion in se- lec ed cases [18]. A mild deg ee o degene a i e changes is pa aphysiological and should be conside ed pa hological only i abno mali ies de e mine symp oms [10]. The signi i- cance o adiological indings needs o be u he discussed. Recen li e a u e has sugges ed ha ne e comp ession is an impo an inding ha may con ibu e o he p edic ion o symp oms [9]. An associa ion be ween ecen lowe back pain and endpla e changes, disk degene a ion, annula ea s o ace degene a ion was no ound o be a isk ac o in a h ee-yea ollow-up. In addi ion, only limi ed in o ma ion o he associa ions be ween occupa ional musculoskele al diso de s, induced disabili y and physical pe o mance is a ailable among mili a y pilo s. Howe e , i has been sug- ges ed ha a high le el o muscula i ness p o ec s agains disabili y bu no wo k- ela ed diso de s [25]. The e is only limi ed epidemiological e idence o he associa ions be ween pilo s’ physical pe o mance and occupa ional musculoskele al diso de s [25]. Long- e m, comp ehensi e ials and/o ollow-ups on his issue do no exis in he mode n ae omedical li e a u e, so he e is an e iden equi emen o his kind o s udy design. The e o e, he aim o he p esen s udy was o g ade and examine p e-ca ee MRI indings among pilo candida es and e alua e hei impo ance in he p edic ion o wo k- ela ed musculoskele al diso de s du ing subsequen ligh aining. Simul aneously, he baseline le el in pilo s’ oc- cupa ional physical pe o mance and i s associa ion wi h pe cei ed ligh -induced symp oms du ing he ea ly ligh ca ee we e de e mined. Ma e ial and me hods Da a we e ob ained om 73 ou o 88 pilo s who had unde gone p e-ca ee MRI o he ce ical and lumba spine. Thei mean age du ing he ligh phase was 26.9 ± 1.5 yea s, heigh 178 ± 5 cm, body mass 77.0 ± 7.0 kg, and body mass index (BMI) 24.1 ± 1.8 kg m–2. Thei o al mean accumula ed lying ime was 673 ± 228 h and ime in high-Gz capable ai c a (Hawk and F-18) was 504 ± 120 h. Fi een pilo s we e excluded om he analysis. Two o hem had ejec ed du ing hei ca ee , 3 pilo s lacked ce ical o lumba MRI o a comple e medical his o y, and 10 o hem had been pulled ou o igh e aining due o a ious easons. The excluded pilo s did no di e om he s udy sample in hei age o BMI. Two pilo s, whose igh e pilo aining had been e mi- na ed due o back p oblems, we e, howe e , included in he analysis. A e ospec i e, e idence-based analysis o neck and back pain his o y du ing ea ly igh e pilo aining was unde aken using in o ma ion om medical cha s (pilo s’ medical appoin men s o ligh -induced pain) [25]. The a e age ollow-up ime a e he MRI examina ion was 6.5 yea s ( ange om 3.8 o 7.0 yea s). The MR images we e analysed by one MRI-expe ienced medical doc o , specialized in physical ehabili a ion, in a blinded ashion independen ly om clinical in o ma ion. The MR exam- ina ions we e pe o med wi h a 1.0 T de ice (GE Signa Ho izon, UK), and hey included he T1 and T2 weigh ed sagi al and axial MRI o he ce ical and lumba spine. The g ading o indings in he ce ical spine [17] is p e- sen ed in Table 1, and he g ading o he lumba spine indings [29] is p esen ed in Table 2. The design o his s udy was app o ed by he E hical Commi ee o he Cen- al Finland Heal h Ca e Dis ic (Jy äskylä, Finland) be- o e da a collec ion. The MRI indings we e linked wi h clinical complain s du ing he ollow-up. These complain s we e g aded om 0 o 2 (0 = no symp oms, 1 = mode a e and empo- a y symp oms, and 2 = se e e o con inuous diso de s, e.g. scia ic symp oms, con i med disk bulges wi h clini- cal symp oms). An expe imen al physical pe o mance es p o ocol was conduc ed in he pilo selec ion p oc- ess o assessing he ligh cade s’ “occupa ional speci ic i ness” cha ac e is ics. All es s we e conduc ed by an ae ospace physiologis in he Ae omedical Cen e (Hel- sinki, Finland). Six y-se en pilo s, who al eady had MRI esul s a ailable wi hin 6 mon hs o he es s, we e ol- lowed up on a e age o 5.4 yea s ( anging om 3.8 o 7.0 yea s). The d op-ou o six pilo s was due o he lack o some physical pe o mance es s. The es s consis ed o Disk nucleus signal P olapse Bone ma ow signal 1 = no signal loss 1 = no p olapse 1 = no in ensi y change 2 = mode a e signal loss 2 = p o usion 2 = in ensi y change 3 = o al loss 3 = p olapse Table 1. G ading o MRI indings a he ce ical spine le el B ough o you by | Tampe e Uni e si y Lib a y Au hen ica ed Download Da e | 12/4/17 10:37 AM Figh e pilo ’s MRI and physical i ness 135 e alua ion o ae obic powe by indi ec maximal oxygen up ake wi h a bicycle e gome e (E goline 800, Bi z, Ge - many) [26], anae obic powe by coun e mo emen jump on a con ac ma wi h addi ional mo o con ol e alua ion, isome ic maximal neck and unk o ce measu emen s [3], and 1 kg medicine ball h ow h ough in a- ed pho o cells wi h a maximal e o (New es T unk/Neck o ce and Powe ime , Kempele, Finland) [22]. The medical ap- poin men s due o he ligh -induced pain we e associa ed wi h he pilo candida es’ physical pe o mance le el du - ing he selec ion phase. The le el o ag eemen (kappa alue) in he adiologi- cal a ing o e e y MR image was calcula ed by he same eade (physia is ) in wo sepa a e eadings. The in a- obse e ag eemen o MRI a ings was 92% (0.58). Bi- na y logis ic eg ession analysis was used o de e mine he associa ion o MRI indings wi h he incidence o symp- oms. The odds a ios (OR) and 95% con idence in e als a e p esen ed. An e idence-based ligh -induced pain in- cidence cu e was c ea ed acco ding o he eal medical appoin men s, and a Poisson uni a ia e eg ession model was used o p edic (RR, ela i e isk; 95% CI) he ligh - ela ed pain incidence wi h he le el o physical pe o m- ance. The signi icance le el was se a p ≤ 0.05 in all s a- is ical analyses. Resul s Eigh y- wo pe cen o he ce ical and 92% o he lum- ba spines we e obse ed o ha e abno mali ies a a leas one disk le el. No signi ican ce ical degene a ion was ound in he p e-ca ee MRIs. All a ed changes in he ce - ical spine we e indica ed by only mode a e signal loss in in e e eb al disks, and he e we e no disk p o usions o bone ma ow signal in ensi y changes. These indings we e mos common a he ce ical e eb a 5- ho ax e eb a 1 (C5-Th1) le el. Ra ed degene a i e changes in he lumba spine we e ound as ollows: 41 subjec s had a p o usion a a leas one disk le el (56% o he subjec s), 2 subjec s An e io column Pos e io column 1 = no mal 1 = no ace join degene a ion 2 = disk nucleus signal loss 2 = ace join degene a ion wi hou s enosis 3 = p o usion 3 = ace join degene a ion wi h s enosis o spondylolysis 4 = p olapse 5 = degene a i e lis hesis 6 = os eophy es Table 2. G ading o MRI indings a he lumba spine le el C1-2 C2-3 C3-4 C4-5 C5-6 C6-7 C7-T1 No changes 99 97 97 88 66 42 40 Signal loss in a disk 1 3 3 12 34 58 60 P olapse 0 0 0 0 0 0 0 Bone ma ow signal in ensi y change 0 0 0 0 0 0 0 L1-2 L2-3 L3-4 L4-5 L5-S1 No changes 100 100 95 51 27 Signal loss in a disk 0 0 5 34 25 P o usion 0 0 0 14 42 P olapse 0 0 0 1 1 Lis hesis 0 0 0 0 4 Os eophy es 0 0 0 0 0 Face degene a ion wi h s enosis* 0 0 0 0 3 Table 3. De ailed ela i e occu ence o MRI changes [%] a each ce ical (C) and lumba (L) spine le el be o e ligh se ice. The same subjec can be included in mul iple ca ego ies (n = 73) *The g aded ace degene a ions we e ela ed o subjec s wi h lis hesis, and he igu e o lis hesis includes he subjec s wi h ace degene a ion. B ough o you by | Tampe e Uni e si y Lib a y Au hen ica ed Download Da e | 12/4/17 10:37 AM H. Rin ala e al. 136 had a p olapsed disk (2%), and 3 subjec s had a lis hesis a he L5-SI-le el (4%). One hi d o he pilo s had a medical appoin men due o ligh -induced pain du ing he i s 5.4 yea s om he beginning o he se ice, bu only 16.5% (OR 3.8, CI95%: 0.8 o 18.7) o he ce ical and 16.4% (OR 2.8, CI95%: 0.7 o 11.0) o he lumba MRI indings we e associa ed wi h subsequen symp oms (Fig. 1). Highe -deg ee MRI ind- ings we e associa ed wi h subsequen se e e symp oms only in 6.8% (OR 1.7, CI95%: 0.4 o 7.1) o he pilo s. Mos o hem wi h mo e signi ican indings, e.g., a leas p o usion (g ade 3 o mo e), we e asymp oma ic du ing he ollow-up (28 ou o 37). Ou o 2 pilo s who showed se e e o con inuous ce i- cal symp oms (g ade 2), he i s one had a no mal ce ical MRI, and he o he one had signal loss in he h ee low- es ce ical in e e eb al disks. The e we e 8 pilo s wi h clinical ou comes g aded as 2. Thei lumba MRI indings included 2 no mal, 1 signal loss, 4 p o usions a a leas one disk le el, and one lis hesis. No mal MRI was associ- a ed wi h asymp oma ic ollow-up in 92% o cases in he ce ical spine and in 60% o cases in he lumba spine. Fu he mo e, no signi ican associa ion was no ed be ween p e- ligh ca ee MRI indings and ligh -induced medical appoin men s in he ea ly ligh syllabus. Table 4 shows he pilo s’ main cha ac e is ics in physi- cal pe o mance be o e he ollow-up. In Table 5, he as- socia ions be ween di e en physical pe o mance es esul s and he incidence o any ligh -induced medical ap- poin men a e p esen ed. The pilo s’ luen mo o con ol in he anae obic jumping es and neck lexion o ces had he s onges associa ions wi h ligh -induced medical ap- poin men s and hus in he es ic ion o he occupa ional ela ed musculoskele al diso de s. Table 4. Figh e pilo s’ (n = 67) physical pe o mance and backg ound cha ac e is ics du ing he selec ion phase Va iable Mean SD Age, yea s 18 – BMI 24.1 2.3 Ae obic powe [W/kg] 4.2 0.5 Anae obic powe [W/kg] 24.9 7.2 Neck lexion [N] 221 52 Neck ex ension [N] 294 48 T unk lexion [N] 660 156 T unk ex ension [N] 900 146 Ball h ow ime [ms] 220 15 Table 5. Associa ion ( ela i e isk, RR) be ween he pilo s’ di e en physical pe o mance es esul s and hei medical appoin men s because o any ligh -induced musculoskele al diso de du ing he ollow-up (n = 67) Tes RR p Ae obic powe 1.0 0.009 Anae obic powe 1.01 0.393 *mo o con ol in jumping 0.46 <0.001 Neck lexion 0.96 <0.001 Neck ex ension 1.02 0.084 T unk lexion 0.99 0.106 T unk ex ension 1.00 0.595 Ball h ow ime 1.00 0.247 Discussion This s udy lays he basis o a ligh -ca ee long ol- low-up by de e mining he essen ial in o ma ion o he wo p ac ical occupa ional a iables o u u e pu poses. Nei he he MRI indings no he occupa ional spe- ci ic physical pe o mance indispu ably p edic ed ligh - induced musculoskele al pain a a s a is ically signi ican le el du ing he ea ly yea s o he ligh se ice. E en mos o he pilo s wi h highe -deg ee MRI indings in he lum- ba spine we e asymp oma ic du ing he ollow-up despi e ha ing unde aken high-Gz lying. So a in ou s udy, Gz exposu e seems o ha e no bea ing on musculoskele al symp oms i espec i e o he occu ence o mo phological changes in he spinal s uc u e. These esul s a e simila o Je aine ligh yea s 0 1 2 3 4 5 6 7 8 9 10 Medical appoin men s due he ligh -induced pain [%] 0 10 20 30 40 50 60 70 80 90 100 Fig. 1. Associa ion be ween je aine ligh yea s and medical appoin men s because o ligh -induced, ligh se ice dis u bing musculoskele al pain (n = 67) B ough o you by | Tampe e Uni e si y Lib a y Au hen ica ed Download Da e | 12/4/17 10:37 AM Figh e pilo ’s MRI and physical i ness 137 hose o ea lie non-pilo s udies [5, 6, 9, 14] and some ob- se a ions made among Gz-exposed popula ions [7, 24]. Howe e , no mal ce ical MRI seems less likely o be subsequen ly associa ed wi h neck pain. The incidence o ce ical disk degene a ion changes was highe in his s udy compa ed wi h ea lie simila s udies, bu he deg ee o degene a i e changes was low- e [5, 19, 28]. This may be due o he ac ha he sub- jec s ep esen ed a popula ion selec ed wi h e y special c i e ia. Mos changes we e loca ed in he lowe ce ical spine, which is con a y o he s udy o Abdulka im e al. [1] which sugges ed ha indings in he ce ical spine a e dis ibu ed e enly a a young age bu end o occu in he lowe disks wi h inc easing age. I imaging o he neck and back we e used in selec ion, some challenging ques ions – such as wha would be conside ed c i ical o p edic i e indings, and how c i e ia o he ejec ion o asymp oma ic ec ui s wi h pa hological indings should be es ablished – would need o be ho oughly discussed. The lumba spine MRI indings and hei ou comes we e also well in line wi h ea lie s udies [6, 9]. The le el o changes seems o be concen a ed in he lowe lumba spine. The incidence o musculoskele al symp oms ei he in he ce ical o lumba spine was ob iously sligh ly low- e han a es epo ed in he li e a u e [12, 15]. The e migh exis non-disabling symp oms ha do no lead an indi idu- al o con ac occupa ional heal h ca e se ices in he ea ly phases o he ligh syllabus. This migh pa ially explain why he incidence o ligh -induced medical appoin men s showed a s eeply ascending end in he p esen ollow-up (Fig. 1). Secondly, his end e lec s quickly cumula ing physical load in he la e ligh se ice, and hus may lead o an inc easing amoun o wo k- ela ed, mo e disabling symp oms. The ollow-up ime was no long enough in iew o he cumula i e indi idual G exposu e. This is an in e es ing phenomenon in ae ospace physiology and su ely needs mo e esea ch o be de ined and measu ed. Howe e , as clinical in o ma ion was based on he pilo s’ medical eco ds, he e was no ecall bias ha may be a ac o in any e ospec i e ques ionnai e. O he occupa ional (non-Gz ela ed) o leisu e ime physical loadings may also cause musculoskele al symp- oms and degene a ion. De e minan s o hese ypes o phenomena a e no adjus able du ing a pilo ’s ca ee , and hey ha e been epo ed o ha e only a modes in luence on degene a i e changes [4, 30]. Symp oms o he han ligh - induced ones also a ec pilo s’ i ness o ly and hei qual- i y o li e. Al hough he e ec s o physical ac i i y we e no e alua ed in his s udy, i is sugges ed ha he co ela ion o physical ac i i y wi h ligh - ela ed musculoskele al diso - de s should also be examined in u u e s udies. The young pilo s pe o med qui e well in he physical pe o mance es s compa ed o he li e a u e [3, 26, 28], bu he a e age esul s we e only ba ely sa is ac o y com- pa ed o ypical endu ance o s eng h spo s a hle ic le els [20]. The physical pe o mance, like he MRI indings, was mainly no associa ed wi h pe cei ed pain, which e lec s well he mul i ac o ial na u e o his issue. The absolu e physical pe o mance, compa ed o a hle es, was poo o only sa is ac o y in di e en es s [22], bu he pilo s we e qui e good in e ms o mili a y pe o mance, in gene al. Jumping skills seemed, howe e , o conside ably educe he numbe o ligh -induced medical appoin men s. Ob i- ously, o e all exe cising has c ea ed such a good body bal- ance, co e muscle s abili y and pos u e ha i has p o en o be occupa ionally bene icial. High neck lexion and ex- enso muscles’ s eng h, as a p o ec i e ac o , p obably ep esen an ideal agonis -an agonis ela ionship; how- e e , muscula balance was no measu ed in his s udy. Excellen physical pe o mance will educe he induced wo k- ela ed disabili y du ing he whole ligh ca ee [25]. Howe e , due o he sho - e m design used in his s udy, i is so a impossible o conclude whe he he measu ed physical pe o mance and, especially, i s changes a e as- socia ed wi h pe cei ed pain in he u u e. The pilo s we e ob iously young, a he e y beginning o hei ligh ca- ee , and no ele an con ols exis ed. A e he e any p edic able issues ha could be ega ded as wa ning signs o la e spinal p oblems? Mino o e en mode a e changes may o may no esul in symp oms du ing he la e phases o a pilo ’s ca ee . S udies among non-pilo s indica e ha ne e oo con ac s a e he mos p edic able indings o pain. Howe e , MRI indings a e no p edic i e o he de elopmen o du a ion o back pain and ice e sa. Indi iduals su e ing om p olonged back pain may no ha e he g ea es deg ee o ana omical ab- no mali y [6]. Longe ollow-up could yield mo e in o - ma ion abou de eloping degene a i e changes and hei ela ionships wi h di e en phases o ligh aining (i.e. di e en G- o ces). I could also be use ul o assess he su ounding so issues such as muscle and a mass and i s loca ion, and elas ic s uc u e including connec i e is- sue ypes, o seek new associa ions be ween wo k- ela ed symp oms and pe o mance. Some limi a ions mus be discussed. The ollow-up ime was no equal o each subjec , which esul ed in de- ia ion in comple ed aining ( ligh hou s) and Gz expo- su e. Howe e , he pilo s had comple ed hei minimum basic and ac ical je aining. Those ones whose ca ee di e ed om ac i e lying wi h high pe o mance ai c a o who had been pulled ou om ai comba aining we e excluded om he ma e ial. Thus, i was conside ed ha he ollow-up da a we e homogeneous enough o enable eliable e alua ion o he ou come o he MRI indings and p edic ion o de eloping symp oms. 1.0 T MRI de ices a e also al eady subs i u ed by mode n equipmen . Thus, i migh be possible ha he baseline indings migh ha e B ough o you by | Tampe e Uni e si y Lib a y Au hen ica ed Download Da e | 12/4/17 10:37 AM H. Rin ala e al. 138 been mo e accu a e wi h he newes me hods. Ha ing only one eade o in e p e images has i s p os and cons. On one hand, he e is no a ia ion in opinions when a single eade pe o ms g ading; on he o he hand, he absence o con ol eade s may esul in unp o en opinions. Hence, i was conside ed ha he use o jus one eade in his s udy was a ele an me hod in e ms o occupa ional medicine. Fi ness es s we e no conduc ed exac ly a he same ime as MR imaging, bu he p o ocol was a anged du ing he same p e- ligh phase wi h MRIs in he ligh syllabus, in he same i ness es labo a o y, and by he same es pe - sonnel and weekly calib a ed equipmen . This may be one o he i s s udies whe e mili a y pilo s’ MRI and physical pe o mance we e e alua ed o- ge he in de ail wi h la e clinical ou come. As he esul s o his s udy do no indica e a clea co ela ion wi h he ce ical o lumba MRI, physical pe o mance and subse- quen symp oms in he ea ly ligh syllabus, mo e ollow- up ime o he syllabus is needed, especially up o ac i e ligh se ice and e i emen yea s. Mino degene a i e changes do no seem o cause se e e diso de s despi e ex- posu e o high Gz loadings, which sugges s ha i could be aluable o emphasize ne e oo con ac s and clea ly de o med spinal s uc u es in he pilo selec ion p ocess. Clinical co ela ion is essen ial o de e mine he impo - ance o abno mali ies on magne ic esonance images, which should also be used o de e mine he su ounding issues s a us, i.e. body a and ac i e issue balance and he ci cum e ence o he ac i e muscula issue, no jus o make no es on bone s uc u e anomaly. Occupa ional- o ien ed physical pe o mance and especially i s changes should be included e en in he basic mili a y i ness es - ing o ae omedical examina ion p ocedu es o cla i y he impo ance in he igh e pilo s’ ca ee -long occupa ional pe o mance. Re e ences 1. Abdulka im J.A., Dhingsa R., Finlay D.B. (2003) Mag-Abdulka im J.A., Dhingsa R., Finlay D.B. 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