SYLLABUS for the presentation by John Christman, Ph.D., at the 5th annual Uniformed Services Recruit andd Trainee Healthcare Symposium, April 28 - May 1, 1999, at the Beaufort Island, South Carolina Naval Hosptial. PROGRESS REPORT ON A PROPOSAL TO ADD SPECIFIC STRETCHING AND STRENGTHENING EXERCISES TO PRESCRIBED MILITARY PHYSICAL TRAINING TO IMPROVE THE LOAD-CARRYING CAPACITY OF THE HEAD AND UPPER BODY ("SLIDES" are the slides shown during the talk, followed by the additional points made about each slide.) John V. Christman, Ph.D., FiTelligence, Inc. ABSTRACT: The increasing weight of helmet-borne instrumentation, and the high incidence of neck injuries in fighter pilots, indicate a widespread military need for improved head support. The increasing weight of the gear carried by ground personnel has also increased the importance of general load-carrying capacity. Conscientious physical training, with a well-designed heavy resistance component, is only a partial solution to these weight-bearing issues. Postural alignment, and the muscles flexibilities and strength balances which produce it, must also be addressed for optimal load-carrying capabilities. Correct postural alignment, with the earlobe over the middle of the shoulders and over the hip joint, and with the shoulders back, results in optimal weight bearing capacity in both the head and torso. With correct muscle flexibilities and strength balances, this alignment can be maintained at all times, without conscious effort. But few military personnel have this correct muscular development (as indicated by their inability to maintain proper posture at all times), and therefore they have suboptimum physical performance capabilities. Rather than proper posture, a forward jutting head and rounded shoulders are more the norm, especially in recruits. A proposal has been made to all 3 military branches to add 7 to 10 minutes of specific stretching and strengthening exercises to daily physical training to cure this poor posture and establish correct neck, shoulder, and upper back strengths and flexibilities. The Navy review found that the 8 exercises in the program which do not duplicate current Navy training could be easily included in the existing Navy fitness program, and recommended that they be implemented as a part of the Navy Health and Fitness Program. The Army and Air Force evaluations are ongoing, with specific research projects in the planning stages. The ultimate result should be the development of military personnel better capable of handling the physical rigors of military service in the 21st century. Teaching Objectives: Convey the increasing importance of correct upper body biomechanics in military personnel due to the increasing head and upper body loading which modern equipment increasingly has imposed. Establish that current military physical training does not address the development of correct upper body flexibility and strength balances adequately to develop correct upper body biomechanics. Describe a 4 to 8 minute long, 8 exercise stretching and strengthening program which, if added to currently prescribed physical training, could establish proper posture and upper body biomechanics via the development of proper flexibility and strength balances. INTRODUCTION TO THE PROBLEM OF HEAD AND UPPER BODY LOAD- BEARING CAPACITIES Two major problems facing military combatants are avoiding injury from equipment and activity loads, and also minimizing the pain and fatigue caused by those loads to arrive at the battlefield as physically and mentally fresh as possible for optimal battlefield performance. Modern warfare technology is not decreasing those loads, it is increasing them, making peak human performance more difficult to achieve. Yet, because fewer people are necessary now to operate increasingly sophisticated and expensive weapons, the need for peak individual performance is greater than ever, and the potential losses from one person's failure to perform are also greater than ever. Thus, focused effort to deal with areas of increasing physical load makes sense from medical, military, and human standpoints. Two of the areas most subject to increasing physical stress in today's military are the neck, in supporting the head, helmet, and any attached gear, and the upper torso, in supporting heavy body-borne equipment loads, as well as contributing to the support of the head. The stretching and strengthening program proposed in this report would specifically improve the load-carrying capabilities of those areas by improving posture, increasing specific muscle flexibilities or strengths, and improving overall muscle strength balances. At the request of Dr. John Mazzuchi, the Deputy Assistant Secretary of Defense for Clinical and Program Policy, the program has been reviewed or is in review by all 3 military branches. The Navy review by the Naval Aerospace Medical Research Laboratory recommended that the program be implemented Navy-wide as a part of the recommended physical training program. Background: Head support is a challenge due to the proliferation of increasingly sophisticated helmet-mounted instrumentation, and the physical loads which modern vehicles, boats, and aircraft can impose on a person. SLIDE 1: SELECTED AREAS OF NEED FOR IMPROVED HEAD LOAD - CARRYING CAPACITY Helmet-mounted instrumentation (night vision, laser sighting, etc.) in ground troops, and crews of tanks, personnel carriers, helicopters, support aircraft, etc. Small, high-speed water craft (Navy fast attack boats) Fighter pilots - high incidence of neck injuries (57% any year, 85% during career in F-16; forced retirements due to accumulation of injuries) Any task which produces neck, shoulder, and upper back pain and fatigue in the individual Computer or radar operation Administrative/clerical desk work The helmet support problems in helicopter crew are well known. There are anecdotal reports of helicopter pilots attaching a bungey cord from their helmet to the top of the cockpit to help support the helmet during long missions. The neck injury problem in fighter pilots is especially severe. One study of F-16 pilots found a one-year incidence of neck injury of 57%, and a career incidence of injury of 85%. Another Australian study of F-18 and MB326H pilots found that of 52 pilots, 44 had had a neck injury due to high gs, and 20 reported that it interfered with mission completion. Thus, in the battlefield these injuries could be life-threatening for the pilot, as well as other pilots and military forces relying upon him for cover. Overall mission success could be threatened. There is a military need for improved head support in fighter pilots now! The pilots also recognize their need on the individual health level. On April 17 at the Midsouth Air Show in Millington, TN (the new home of BUPERS), a Marine F-18 pilot told me his main health concern now is what frequent forces of up to 8 gs are doing to his spine. He said that he had not been taught any stretching or strengthening exercises to specifically improve his postural biomechanics in order to help him cope with these stresses, or to counteract their effects upon him. And in the previous 2 weeks, he had spoken with 2 F-18 pilots in their mid-30s who were having to quit flying F-18s because they can no longer turn their head to look 90° to either side. Such forced retirements are serious personal and military losses. In a March 5, 1999 news article, "Military pilots bail out: pay isn't only problem", the statement was made that "The Defense Department contends that every time a veteran pilot walks out the door, it costs taxpayers $5.9 million in lost training time and experience". Thus, these 2 F-18 pilots represent a loss of $11.8 million, and will likely incur future costs of medical treatment for their problems. And what percentage of fighter pilots have to similarly retire early? It would seem sensible, from both physical cost and human cost standpoints, that any program which presented a reasonable probability of reducing such physical problems should be a high priority item for evaluation by the military. Finally, awkward, sustained, or extreme working posture is a well-recognized contributor to neck and shoulder stress on the job. A lapse in concentration in a radar operator due to pain or fatigue could have disastrous consequences. Such problems in normal computer operation or administrative work are not so potentially disastrous, but productivity will be reduced, and there is an increased chance of long-term spinal damage from chronic spinal overload. SLIDE 2: SELECTED AREAS OF NEED FOR IMPROVED UPPER BODY LOAD-CARRYING CAPACITY Ground troops - 70 pound average load: pack, weapons, supplies, body armor, etc. Fighter pilots - 7.5-8 g. maximum loading in F18 As for upper body load-carrying capacity, the average infantry load is around 70 pounds, with weapons, supplies, body armor, and all. Army research has had soldiers marching 20 K with 75, 105, and 135 lb packs, an indicator of what the Army considers a realistic performance range. And in fighter pilots, head and helmet support involves the upper body musculature as well as that of the neck. A program which simply reduced fatigue from carrying these head and upper body loads would confer a battlefield advantage by increasing alertness and responsiveness, especially under conditions of insufficient rest and recovery. There are at least 3 ways to improve head and upper body weight bearing: SLIDE 3: 3-PART APPROACH TO OPTIMIZING WEIGHT-BEARING CAPACITY Design safety Weight less than safe limit Minimize weight further to reduce fatigue, thereby increasing mental sharpness Optimize weight placement, especially on the head (a current militaryresearch area) Increase strength of vulnerable body parts Field training Correct weight training (to also improve posture) Develop proper posture and flexibility Increase ability of skeletal system to support weight Increase efficiency of the supporting musculature To increase the strength of vulnerable body parts, there is no substitute for field training, the "specificity of exercise". Nothing can duplicate the load of a 100 pound pack on a long march. But correct generalized weight training can also greatly help, especially if the program is specifically designed to also produce proper, biomechanically efficient posture, and proper flexibility. However, the opportunity, understanding, and motivation to train must be there. In the previously cited F-16 pilots study, which showed 85% total and 57% yearly neck injuries, despite knowing about and experiencing these injuries, only 27% of them routinely did neck strengthening exercises! But conscientious physical training, with a well-designed heavy resistance component, is only a partial solution to increased weight-bearing capacity. Postural alignment, and the muscles flexibilities and strength balances which produce it, must also be optimum for peak load-carrying capabilities. And that optimum development is normal, proper posture and flexibility! The anatomical neutral position maintained with proper posture is the best for spinal support of weight, and the muscles can generate the most force with the greatest efficiency while in that same position, or working from that position. The importance of body segment position is especially illustrated in the head, where changes in its anterior-posterior position greatly affect how much work is necessary to support it: SLIDE 4: The head-neck support system could be likened to a 10 pound ball on a flexible shaft stabilized by guy wires. The muscles pull down to stabilize, so the stronger the muscles, the more force is transmitted through the spinal column. Therefore, the least stress on the spine will occur when the head is basically centered over the spinal column below, so that minimum muscle tension is necessary to hold the head up. This optimal biomechanical position is achieved with what is accepted as normal, good posture. Each inch forward the head is held forward of this position requires the exertion of 15 to 30 pounds of extra muscle tension, which means that that much less muscle strength is available to support outside loads. And, of course, this extra muscular load is transmitted down the spine, increasing chronic loading on the vertebrae as well as the intervertebral discs. The shoulders back and down position of proper posture is also optimal for load bearing. With this position, when a weight is held in the hands or supported by the shoulders, the shoulders will be pulled downwards, but not forwards. When a forward shrug occurs, it is much less efficient, an fatigue resistance drops and the spine is more vulnerable to injury. SLIDE 5: PROPER, OPTIMALLY EFFICIENT POSTURE Line of gravity (within fairly narrow limits): Earlobe over the middle of the shoulders, over the hip joint, and over a point about an inch in front of the ankle joint. Proper posture occurs when: The shoulders are held back and down Thoracic spine curves forward only slightly Scapulae do not "wing out"- they should be flat. The chest curves out - forward tips of the shoulders would not touch a yardstick placed across the upper chest The collar bones are level or slope only slightly upwards From the front, the chin is at least 2 inches, if not 3 or 4 inches, above the clavicular notch and above the acromioclavicular joints. Correct postural alignment, then, is basically the ears over the shoulders over the hips, with the head up and the shoulders back. This posture results in optimal weight bearing capacity in both the head and torso. World-class power lifters all have this posture, both at rest and while lifting. And pictures of people from cultures where heavy loads like water jugs were carried on the head always shows correct posture. This posture also produces the best performance in almost every physical activity. Virtually all world class athletes, in sports where power or endurance are important, have good posture all the time, because the muscular strength and flexibility which produces "automatic" good posture is also the best for force production, muscular endurance, and cardiovascular endurance. (Visualize Mark McGuire and Sammy Sosa; any world-class runner, like sprinter Michael Johnson or distance runner Haile Gebrselassie [26:33 10K]; or any world class power lifter). With correct muscle flexibilities and strength balances, proper posture can and will be maintained without conscious effort at all times, even while standing relaxed. This point is important from a physical performance standpoint, because when you are fatigued or working under stress, you tend to revert to your relaxed posture and alignment. If this relaxed posture is not straight and efficient, you will fatigue even more quickly and perform less efficiently. Do most military personnel have the correct muscular development for optimum physical performance, as indicated by the ability to maintain proper posture at all times? No! Extremely few can or do hold good posture all the time, and therefore have suboptimum physical development. Instead, forward head posture is more the norm. SLIDE 6 Forward head posture involves flexion of the lower cervical spine in combination with extension of the upper cervical spine. It is often accompanied by protracted scapulae and increased thoracic kyphosis. In the general population, the incidence of forward head posture is very high. One study of 88 healthy subjects, ages 20-50, found forward head posture in 66%, kyphosis in 38%, right rounded shoulder in 73%, and left rounded shoulder in 66%. In the military, the incidence of these postures is also extremely high. The figure in slide 6 is not too extreme a representation of the posture of many active duty military personnel. Notice that the figure's head is still above the outer tips of his shoulders. The chin height of many military personnel is below the outer tips of their shoulders, and their head position is farther forward than this. In a current study at the Naval Aerospace Medical Research Laboratory, gridded photographs of 34 aviators in training, aged 22 to 27, showed that all but one have forward head posture with rounded shoulders. Remembering that the earlobe should be over the middle of the shoulder, one person's ear position was over the anterior chest wall. At the Midsouth Air Show on April 17, I observed forward head posture in every flight crew member I saw, including the Blue Angels pilots and ground crew. And finally, the NAMRL evaluation of the proposed program which is the subject of this presentation recommended that "a general assumption be made that the majority of Navy population has a forward head posture and lacks good flexibility in the neck and shoulders". Why is forward head posture so prevalent in military personnel? SLIDE 7: REASONS FOR PREVALENCE OF FORWARD HEAD POSTURE IN MILITARY PERSONNEL A "normal", late 20th-century life history of sedentary, static, hunched forward activities before and during military service. No exercises or habits specifically intended or designed to counteract these deforming influences. Military fitness testing criteria emphasizing flexor motions (pushups, situps), developing muscles which pull the head and shoulders forward and pull the ribcage downward, without adequate counteracting flexibility and strength work. The harmful consequences of forward head, round shouldered, kyphotic posture on physical performance are numerous. SLIDE 8: SAUNDERS MANUAL OF PHYSICAL THERAPY PRACTICE: "Poor posture" is a faulty relationship of the various parts of the body which produces increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support. When resting posture is not "normal", more energy is needed to perform or control movements; e.g., forward head posture puts increased stress on the cervicothoracic spine and requires more work from the erector spinae muscles to maintain an erect posture. (Recall the 15-30 pounds of extra work necessary for each inch of forward head displacement.) The chronic stretching or shortening of muscles with forward head posture also has significant performance-reducing consequences SLIDE 9. EFFECTS OF POOR POSTURE ON THE MUSCLES AND ON THE SPINE Muscles habitually kept in a stretched position beyond the physiologic resting position tend to weaken. This is known as stretch weakness. Muscles habitually kept in a shortened position tend to lose their elasticity. These muscles test strong in the shortened position but become weak as they are lengthened. This is known as tight weakness. Imbalances in the flexibility of hip, shoulder, and neck musculature causes asymmetric forces on the spine (which decrease loadbearing capability and increase injury risk). Kisner and Colby, in Therapeutic Exercise, 3rd edition, state that this adaptive shortening of soft tissues and muscle weakness, caused by prolonged poor postural habits is considered to be a postural dysfunction. Stress to the shortened structures causes pain, and strength and flexibility imbalances may predispose the area to injury or overuse syndromes that a normal musculoskeletal system could sustain. Good postural habits are necessary to avoid postural dysfunctions The specific effects on the joints and muscles of forward head posture, and the kyphotic posture which is typically associated with it, are the following: SLIDE 10: FORWARD HEAD POSTURE - EFFECTS ON MUSCLES            Joints Affected Short Muscles Weak Muscles Atlanto-occipital Levator scapulae Hyoid Cervical spine Sternocleidomastoid Lower cervical and thoracic erector spinae Temporomandibular Scalenes Middle and low  trapezius Scapulothoracic Suboccipital Rhomboids Glenohumeral Upper Trapezius     Pectoralis major     Pectoralis minor   That forward head posture should affect the atlanto-occipital, cervical spine, scapulothoracic, and glenohumeral joints should be obvious. The temporomandibular joint is involved because of forward head posture causes referred muscle tension in the jaw area, as well as causing an abnormal pull on the jaw area. Forward head posture is found in temporomandibular disorder patients more frequently than in normal, painfree dental patients, and many researchers believe that there is a cause-effect relationship between them. However, this viewpoint has not been universally accepted. Shortened pectoralis major and minor, and weakened lower cervical and thoracic erector spinae, middle and low trapezius, and rhomboids will certainly decrease head and torso load-bearing capabilities, as well as decrease general work capacity. SLIDE 11: KYPHOTIC POSTURE - EFFECTS ON MUSCLES Joints Affected Short Muscles Weak Muscles Thoracic spine Intercostales Levator scapulae   Pectoralis major Upper trapezius   Serratus anterior Thoracic erector spinae     Rhomboids     Middle and lower trapezius Again, the shortened chest muscles will reduce work potential. Pulmonary functions are also compromised by kyphotic posture. Shortening of the intercostales, pectoralis major and minor, and serratus anterior increases the work of inspiration, and rounded shoulders impinge upon upward excursion of the ribcage. Kyphosis has been found be to significantly correlated with dysfunctional changes in lung volumes involving residual volume, including total lung capacity, functional residual capacity, and forced expiratory flow rate. Another consideration with both forward head posture and kyphosis is that posture typically worsens with age, resulting in the above dysfunctional adaptations. Therefore, maintaining proper posture, flexibility, and range of motion may help minimize age-related decline in physical performance. Certainly, one sees good posture in the best age-group runners and triathletes. To summarize the effects of forward head, round-shouldered posture on the muscles and spine, these postures: Decrease the load-bearing capabilities of the spine Increase the loading on its supportive musculature Decrease the flexibility and strength of that supporting musculature. Reestablishing normal posture and flexilibility will improve muscle function and load supporting capabilities in the head and upper body. The elimination of forward head and kyphotic postures would also have positive effects beyond the improved muscle function and load supporting capabilities in those areas. SLIDE 12: BETTER PILOT VIGILANCE WITH PROPER POSTURE AND NECK FLEXIBILITY Greater upward gaze compared to forward head posture Greater rotational range (left and right) due to: No chin to shoulder interference Proper neck muscle flexibility The atlanto-occipital joint is more vertical with proper posture than with forward head posture, so upward rotation range of motion of the head is greater. Even if helmet contact with the neck is the limiting factor in upward rotation, upward rotation will still be greater with proper posture, because the neck is vertical, rather than sloping forward. Rotational range of motion left and right will be greater because the chin will be properly higher than the shoulders, so there will be no chin to shoulder interference. And if the shortened neck muscles associated with forward head posture have been properly retrained, neck flexibility will be greater. These changes are in addition to the fact that less fatigue from proper flying posture in fighter pilots means less chance of injury when g-loading does occur. Now is increased pilot vigilance really necessary? SLIDE 13: RECENT HEADLINES 31 July, 1998: "Airman dies after Navy jets collide" ROME - Two U.S. Navy F-14 Tomcat fighter jets collided Thursday over the Mediterranean during routine operations, and one crewman died after ejecting from a jet that crashed. 29 January, 1999: "Warplanes collide, crash in Fla. Gulf" EGLIN AIR FORCE BASE, Fla. - A pair of F-15 Eagle fighter jets collided Thursday afternoon and crashed into the Gulf of Mexico. The jets ..... were on a training mission. The fact that accidents like these continue to happen indicates that greater vigilance capabilities need to be continually sought Another area of potential benefit is general back safety. SLIDE 14: FORWARD HEAD POSTURE AND BACK SAFETY Misalignment in the upper back, neck, and head results in a compensatory, dysfunctional adjustment in the lower back to maintain balance over the hips Thus a lower back safety program which does not address upper torso and head alignment will not optimally prevent injuries or reduce healthcare costs. The excess backward curvature from the kyphosis usually associated with forward head posture typically results in excess lordosis, or forward curvature, in the lower back, increasing chronic strain and decreasing overload tolerance in that area. Thus a lower back safety program which does not address upper torso and head alignment will not optimally prevent injuries or reduce healthcare costs. Besides helping to reduce lower back problems, proper neck, shoulder, and upper back posture and flexibility will decrease or eliminate the typical pain and fatigue which so many people interpret as "job stress", but which is really biomechanical overload from improper posture. Professions which have a high incidence of neck and back problems, like dentistry and surgery, will especially benefit. And in desk jobs, the neck, shoulders, and upper back will be no more fatigued at the end of the day than the rest of the body with proper posture and flexibility. PROGRAM PROPOSAL What type of program is necessary to effectively and quickly cure forward head, round-shouldered posture, and reestablish normal flexibility and range or motion? How complicated does it have to be, and how much time must it take? SLIDE 15: FORWARD HEAD POSTURE CURE Practicing "straightening up" may slowly cure forward head posture, but it will not totally reverse the loss of flexibility associated with such posture. Active exercise intervention, to specifically correct the strength and flexibility deficits associated with forward head posture, is necessary for a time-effective, assured cure. The program being proposed here is such a program. SLIDE 16: EXERCISE REQUIREMENTS TO CURE FORWARD HEAD POSTURE AND NORMALIZE FLEXIBILITY Add 8 stretching and strengthening exercises to current prescribed Navy physical training Time cost: 4 to 8 minutes daily Equipment costs: $0 Facilities costs: $0 Initially, to correct posture and flexibility shortcomings, it could take 10 to 15 minutes daily, though 4 to 8 minutes would be more typical. Once posture and flexibility have been normalized, the program would only take about 4 minutes per day. In fact, the program could effectively take no extra time at all, because most of the exercises could be done interspersed between other activities throughout the day. Equipment costs and facilities costs would be zero, because the only requirement is a place to be able to lie down. The 8 exercises to be added to daily physical training, and how they effect the muscles involved in each of them, are: SLIDE 17: RECOMMENDED EXERCISES AND THEIR EFFECTS 1.    Elbow Lift Behind the Back Stretches 2.    Neck Stretching Stretches 3.    Chin Glides Stretch and Strengthen 4.    Shoulder Rolls Stretch and Strengthen 5.    Standing Stomach Strengthener Strengthens 6.    Back Flattening Stretches and Strengthens 7.    Upper Spine Straightener Stretches and Strengthens 8.    Air Rowing Stretches and Strengthens When added to the already recommended exercises of sit and reach (or long sitting), stomach crunches, and the side of chest and outer back stretch, they would provide a curative program for forward head posture and its associated muscle flexibility deficits. Two of the exercises, the back flattening and the upper spine straightener, were specifically invented for this program to work areas which no current stretching or strengthening exercises target. The program produces effects within days if proper exercise form is learned and followed. In addition to causing chronic change, these exercises can be used to provide immediate relief whenever needed from muscle tension in the neck, shoulders, and upper back. Doing these exercises both during regular PT and as needed tends to raise people's consciousness of posture-related pain, so that they act sooner and as needed to prevent pain and fatigue. By decreasing the muscle overload which causes this pain and fatigue, there should be fewer long- term problems with the muscles and the spine. Other than the minimal time it takes to do these exercises, I can see no downside to this program, only the very significant benefits of developing proper posture, flexibility, and muscle balance. IMPLEMENTATION NEEDS AND SUGGESTIONS At this stage, study data on military populations is probably necessary to justify service-wide implementation of this program. I would certainly greatly appreciate input from anyone reading this report on how to facilitate the testing process, up to and including doing collaborative research. The actual implementation of this program would be quick and optimally effective using the following plans. SLIDE 18: IMPLEMENTATION SUGGESTIONS Videotape: The described 8 stretching/strengthening exercises General stretching instructions (static, pnf, etc.) Information on proper weight training program design. Provide this videotape to: All drill instructors All active-duty personnel or training groups All enlistees to use between enlistment and induction (optimally, include information on all prescribed PT) All ROTC units All Reserve units First, I would propose a video because it is the best way to teach movement. There is virtually no chance of misinterpreting visual instructions, whereas there is a great chance of it with written instructions, even with illustrations. If the effort is going to be made to implement this program, do it in the manner which will produce optimal results, to justify that effort! Instruction on proper weight training would be helpful because incorrect weight training can actually worsen posture and flexibility and increase injury risk. The reason is that many strengthening programs overemphasize flexion activities of the trunk, hips, and shoulders, and protraction (forward movement) of the scapulae, without including a comparable number and intensity of exercises to extend the trunk, hips, and shoulders, and retract the scapulae. While developing a strength imbalance between antagonistic muscle groups by overdeveloping the flexors, if there is stretching component to these programs it will usually overstretch the extensors. With short, tight muscles on one side of the joint, and flexible, weak muscles on the other, injuries and generally suboptimal physical performance are the most probable outcomes. So instruction on how to develop a "posture friendly" weight training program would be a useful inclusion in any posture development program. The reasons for providing the video to the listed groups are the following. Obviously, all drill instructors, to start new recruits off correctly. Active duty personnel who are responsible for their own training would also need access to the program. Providing it to enlistees would allow them to start improving their posture and flexibility immediately, for an easier time during basic training and less chance of developing an overuse injury. Similarly, ROTC members could be sure that their training program is optimal. And with the increasing role of the Reserve in today's downsized military, anything to increase their fitness and health consciousness, and therefore their performance level and physical reliability, would be a step in the right direction. A final note on potential costs of implementing such a program through all 3 military branches is this: The multimillion dollar cost represented by the premature retirement of just the 2 F-18 pilots I mentioned earlier in this presentation is more than it would cost to make this video, covering all of the topics listed, and then making a copy for every one of the 1.4M people on active duty with the U.S. Military. The results would not only be a reduction in such premature retirements, but the overall development of personnel better capable of handling the physical and mental rigors of military service in the 21st century!