Evidence-based decision-making has garnered significant support in public health practice and policy in recent years and has contributed to the development of research priorities. Contemporary injury prevention practice and policy should be guided by a systematic evaluation of the best evidence available. A systematic review of the available evidence can also aid in identifying knowledge gaps that need to be addressed through research to advance injury prevention priorities. Jones et al. [4] recently described a systematic process for evidence-based decision-making and injury prevention in the military. The evidence-based decision-making process described by Jones et al. [4] focused on six steps including: (1) ­identifying the biggest or most severe injury problems; (2) systematically searching and reviewing the existing scientific evidence on effective injury prevention interventions based on the injury prevention priorities established in step 1; (3) objectively evaluating the quality of the individual research studies identified in step 2 using ­established review criteria; (4) making injury prevention recommendations based on the overall strength and consistency of the evidence; (5) prioritizing injury prevention ­interventions based on available resources, the magnitude and severity of the problem, the efficacy and effectiveness of interventions, and feasibility; and (6) identification of research gaps and priorities. Important aspects of the evidence-based decision-making process for injury prevention outlined above include evaluating the quality and findings of individual studies, and synthesizing the results across studies, to make evidence-based recommendations grounded in the strength and consistency of the available evidence. To address the latter, the authors provided criteria for making recommendations on injury prevention strategies based on the synthesis of effects across studies [4]. They also provided criteria and tools for establishing injury prevention practice and research priorities in the military .

Canham-Chervak et al. [27] applied this systematic approach for prioritizing injury prevention activities in a separate paper in the same special issue of the American Journal of Preventive Medicine. Their stated objectives were to (1) refine previous prioritization efforts by systematically utilizing input from experts with public health training and experience evaluating epidemiological data and the scientific literature, and (2) apply defined criteria to identify top DoD injury causes most amenable to implementation of injury prevention programs and policies [27]. Musculoskeletal injuries and conditions due to physical training were identified as the top priority for injury prevention, followed by military parachuting injuries, injuries due to privately owned motor vehicle crashes, and sports-related injuries. These and other leading causes of injury in the military were systematically evaluated using the following criteria: (1) importance of the problem to health and military readiness, (2) preventability of the problem, (3) feasibility of injury prevention or policy interventions, (4) timeliness of implementation and results, and (5) ability to evaluate programs or policy outcomes. Though the authors applied a systematic approach to identifying injury prevention priorities, they noted some limitations associated with the process and areas for improvement. A primary limitation was that the process relied on cause of injury coding from hospitalization data and did not include cause of injury for outpatient encounters [27]. This is an important limitation because the majority of musculoskeletal injuries and conditions are treated in outpatient clinics. Despite the significant advances in injury surveillance within the military, accurate cause of injury coding for outpatient encounters remains problematic in the military health system. A key area for improving the systematic process for establishing injury prevention priorities focused on involving the raters earlier in the process so that they could have input into the final criteria and methods used; however, the authors noted the need to balance scientific rigor with the need for a timely response to pressing public health issues might preclude this in public health practice [27].

Ruscio et al. [28] applied a similar systematic process to identify injury prevention priorities based on injury type, cause of injury, and morbidity measured by the number of limited duty days associated with injury. The authors reviewed hospitalization data and data for outpatient encounters documented in the DMSS for 2004. They identified the leading injury types by body region for acute injuries and injury-related musculoskeletal conditions. The authors also estimated the number of limited duty days for each diagnosis by body region. Limited duty days for the top five acute injuries resulting in outpatient encounters were (1) lower extremity fractures which resulted in 7928 person-years of limited duty (20 %), (2) upper extremity fractures which resulted in 6450 person-years of limited duty (17 %), (3) lower extremity sprains and strains which resulted in 5144 days of limited duty (14 %), (4) lower extremity joint dislocations and cartilage tears resulting in 4166 person-years of limited duty (11 %), and (5) sprains and strains to the spine and back which resulted in 3293 person-years of limited duty (9 %). Limited duty days for the top five injury-related musculoskeletal conditions requiring outpatient care were (1) lower extremity overuse injuries (pain, inflammation, and stress fractures) which resulted in 10,420 person-years of limited duty (34.5 %), (2) overuse injuries to the torso (pain, inflammation, and stress fractures) which resulted in 5933 person-years of limited duty (19.6 %), (3) upper extremity overuse injuries (pain, inflammation, and stress fractures) which resulted in 3600 person-years of limited duty (11.9 %), (4) unspecified overuse injuries (pain, inflammation, and stress fractures) which resulted in 2737 limited duty days (9 %), and (5) lower extremity sprains, strains, and ruptures which resulted in 1896 person-years of limited duty (6.3 %). These data systematically provide a measure of the impact of musculoskeletal injuries in the military population, specifically in terms of work-related disability associated with the leading diagnoses for musculoskeletal injuries and conditions among service members. In addition to quantifying the burden of these injuries in terms of military readiness, they also provide objective data for developing injury prevention priorities .

The causes of the top acute injury diagnoses were also examined [28]. Transportation-related accidents (e.g., motor vehicle or vessel) were the leading cause of upper and lower extremity fractures and sprains and strains to the back. Sports and physical training were the leading cause of lower extremity sprains, strains, and dislocations. Sports and physical training was also among the top three causes for all of the other leading diagnosis categories examined. Using the systematic process described above by Jones et al. [4], service-specific injury prevention program and policy priorities were established based on these data (Table 14.2) [28]. Sports and physical training-related musculoskeletal injuries were identified as a leading priority for injury prevention and policy prioritization across the services. Based on these data, the authors made recommendations for injury prevention interventions [34] that included (1) evaluating environmental, behavioral, directive, or regulatory interventions to prevent injuries related specifically to sports and physical training; (2) endorse evidence-based recommendations from systematic reviews for sports and physical training-related injury prevention, including but not limited to parachute ankle braces, mouth guards, breakaway bases for softball, and ankle braces for sports with high risk for ankle injury such as soccer and basketball; (3) provide resources and policy priority to the biggest, most preventable problems identified which include, but are not limited to, sports and military physical training, falls, and privately owned vehicle accidents; and (4) endorse the Joint Services Physical Training Injury Prevention Working Group’s recommendations for the prevention of physical training-related injuries [29].