INTRODUCTION: Neck pain during military flight is well documented. Characterizing operationally relevant, specific pain location(s), severity, character, and exacerbating or relieving conditions is needed to develop musculoskeletal neck pain prediction models.

METHODS: An anonymous, web-based questionnaire and weighted numerical response index was developed with the help of an expert clinical panel. The questionnaire was reviewed, approved, and disseminated to military pilots. Respondents reported their current neck and upper back musculogenic and neurogenic pain with a 5-level severity at 14 locations, pain onset time, duration, and relief measures, and three-axis neck mobility.

RESULTS: Of 222 fixed and rotary wing pilot respondents, 117 completed questionnaires were used for index calculation. Bilateral moderate musculogenic and neurogenic pain in the 10 posterior muscle areas was most common. Flexor muscles were infrequently indicated. Typically, neck pain started within 30 min of flight or pilots were already in pain, pain duration was less than 7 d, and pain was relieved by rest with over-the-counter medications or by a chiropractor or physical therapist. Neck motion limitations were equally rated as very limited, slight, or no restriction. The normalized index was divided into five ranges where 78% were very mild to mild severity.

DISCUSSION: This new approach differentiates between musculogenic and neurogenic pain by discrete location and severity, addressing pain pattern, structural involvement, and neck mobility changes beyond pain absence or presence. This information can help define necessary model complexity to simulate neck pain biomechanics. The index has potential medical use in tracking pain progression and treatment progress.

Whitley PE, Shender BS, Shivers BL. Initial evaluation of the Operational Neck Pain Index. Aerosp Med Hum Perform. 2025; 96(5):367–377.

INTRODUCTION: The military aviation environment is inherently noisy, with occupational noise hazards from a variety of sources. At the same time, it demands good binaural auditory acuity and speech discrimination abilities for the safe and effective performance of flight duties. This study aimed to 1) examine the burden, characteristics, and severity of abnormal audiograms among military aircrew and ground-based aviation personnel in the Republic of Singapore Air Force; and 2) elicit the risk factors associated with abnormal audiograms.

METHODS: In this cross-sectional study, anonymized data (sociodemographic information, pure tone audiometry thresholds, anthropometric and physiological measurements, and biochemical investigations) were extracted from all consecutive unique annual certification examinations performed between January 1 and December 31, 2022. Multivariable logistic regression was performed to identify statistically significant risk factors associated with abnormal audiograms.

RESULTS: Of the 1817 audiograms, 83 (4.6%) were abnormal based on the modified World Health Organization criteria. Abnormal audiograms featured an early bilateral high-frequency hearing loss pattern characteristic of noise-induced effects. The multivariable model retained only age and four vocations [i.e., Communication Equipment Specialist, Air Force Engineer (Flight Engineer), Air Warfare Officer (Air Battle Manager), and Unmanned Aerial Vehicle Pilot] as significant risk factors. Neither aircraft platforms nor specific engine types were associated with higher odds of developing abnormal audiograms.

DISCUSSION: This study suggests that the modified World Health Organization criteria are useful in identifying at-risk subgroups within the military aircrew population and could be considered for use as a more sensitive screening threshold for early noise-induced hearing loss.

Seah BZQ, Ng WT, Gan WH, Low JW, See B. Abnormal audiogram risk factors in military aircrew and ground-based aviation personnel. Aerosp Med Hum Perform. 2025; 96(5):378–385.

INTRODUCTION: Female aviators and aircrew face unique occupational exposures, including noise, whole-body vibrations, toxic chemicals, intermittent hypoxia, and high gravitational forces. We evaluated associations between maternal occupations as aviators and aircrew during pregnancy and adverse pediatric health outcomes.

METHODS: We conducted a retrospective cohort study of children born to female U.S. military officers from October 2002 to December 2019. Exposure was defined as the mother serving in an aviation or aircrew occupation at time of birth. Adverse health outcomes were identified by International Classification of Diseases codes. Cox proportional hazards regression was performed, adjusting for maternal age at delivery, maternal race and ethnicity, and marital status. A post hoc power analysis was performed.

RESULTS: The study included 18,637 female officers. There were 1144 children of fixed-wing aviation officers and 25,889 children of non-aviation officers. There was decreased risk of adverse neurodevelopmental outcomes [hazard ratio (HR), 0.81; 95% confidence interval (CI), 0.68–0.95], speech delay (HR, 0.72; 95% CI, 0.59–0.89), and other and unspecified congenital anomalies (HR, 0.74; 95% CI, 0.60–0.90) for children of aviators. There was no increased risk for any of the adverse pediatric outcomes. Five outcomes had sufficient sample size to detect significance.

DISCUSSION: Although this study suggests that children of military officers in aviation careers do not have an increased risk for adverse pediatric outcomes, it was underpowered and cannot conclusively imply safety of maternal aviation occupational exposures during pregnancy. Further research must evaluate how prenatal exposure to flight affects subsequent pediatric health outcomes.

Royall M, Sorensen IS, Stark CM, Dorr M, Salzman S, Hisle-Gorman E, Dobson N, Brown J, Susi A, Huggins BH, Nylund CM. Pediatric health risks among children of female military aviation officers. Aerosp Med Hum Perform. 2025; 96(5):386–391.

INTRODUCTION: This study examines the health status of pilots above age 60 and its impact on the workforce, focusing on those not returning to work.

METHODS: Pilots from a major Japanese airline reaching age 60 between 2008–2013 were studied for the subsequent 5 yr (“senior pilots”). Disqualifying diseases, application for Aviation Medical Review Board (AMRB), disposition, and grounding periods during the 5 yr were compared with those of a pilot cohort reaching age 55 during the same period (“non-senior pilots”).

RESULTS: There were 263 senior and 202 non-senior pilots. For AMRB cases, cardiovascular diseases were significantly more common in senior pilots compared with non-senior pilots (10.3 vs. 4.0%, respectively). Senior pilots were less likely to apply for AMRB (9.9 vs. 3.5%) or return to work, i.e., the sum of those who were denied by and who did not apply for AMRB (12.2 vs. 5.0%) and also had a higher incidence of cardiovascular diseases (4.6 vs. 1.0%). The grounding period of those not returning to work within the 5-yr study period was significantly longer than the temporary grounding period in both groups of pilots (senior: 22.3 ± 15.7 vs. 6.3 ± 4.7 mo; non-senior: 24.2 ± 17.2 vs. 7.5 ± 8.6 mo, as mean ± SD, respectively).

DISCUSSION: Medical disqualification in senior pilots is more frequent than with younger pilots and may have a greater impact on crew availability. Looking at ways of increasing the number of older pilots returning to work would benefit crew availability as would a focus on the prevention of cardiovascular diseases.

Takazoe K, Gomi H. The health status of pilots over age 60 at a Japanese airline. Aerosp Med Hum Perform. 2025; 96(5):392–398.

INTRODUCTION: Expeditions in remote locations are becoming increasingly commonplace. As the composition of teams change, understanding team dynamics is important to inform subsequent expeditions in challenging environments.

METHODS: Eight individuals (five men, three women; five military, three civilians) completed a ski expedition from the Ronne Ice Shelf to the South Pole over 47 d. A mixed methods observational cohort study was undertaken, involving completing pre-expedition Multidimensional Personality Questionnaires and Portrait Values Questionnaires. During the expedition individuals completed the Isolated and Confined Environments Questionnaire and the Positive and Negative Affect Scale at 7-d intervals. Subsequent semistructured interviews using a topic guide informed by Goffman’s “total institution” were conducted and analyzed using reflexive thematic analysis.

RESULTS: Multidimensional Personality Questionnaire and Portrait Values Questionnaire responses were similar between participants. The Isolated and Confined Environments Questionnaire results showed significant variation with no clear trend. Statistical significance was seen in social and emotional domains between sex and occupations. Positive and Negative Affect Scale scoring demonstrated higher positive affect (mean ± SD; 38.9 ± 1.5) to negative (13.1 ± 1.3). Subgroup analysis demonstrated significance for negative affect between sexes (one result skewed the data). The interviews highlighted that individuals found the routine and lack of personal space challenging. Interpersonal relationships were a source of support but also friction.

DISCUSSION: Despite similar initial questionnaires and experiences during the expedition, subjects used a diverse range of coping strategies. Interpersonal factors remain the most important aspect in ensuring a successful team and pre-expeditionary work should be carried out focusing on this.

Harper P, Albertsen N, Koivula F, Greenfield S, Thomas N. Psychological adaptation in a mixed sex and ability team during a ski expedition to the South Pole. Aerosp Med Hum Perform. 2025; 96(5):399–406.

INTRODUCTION: Coronary artery disease (CAD) is a major health concern in military aviation, representing one of the leading causes of flight disqualification. Traditional screening methods for CAD in military pilots include resting electrocardiograms and exercise stress tests, but these methods have limited sensitivity and specificity. This has prompted the search for more effective tools to assess cardiovascular risk and identify pilots at risk for CAD. One of the most promising tools in this regard is the Coronary Artery Calcium Score (CACS).

METHODS: A comprehensive literature review was conducted using electronic databases, such as PubMed® and Google Scholar, focusing on the use of CACS in cardiovascular risk assessment, particularly in military populations. Relevant studies discussing the application of CACS in pilot screening protocols and clinical recommendations from aerospace medical regulatory bodies were included.

RESULTS: The review highlights the advantages of using CACS over traditional screening tools, including its higher precision in evaluating cardiovascular risk and its ability to detect atherosclerotic lesions at an earlier stage. The findings also explore the potential of CACS to reduce the incidence of CAD-related flight disqualifications by improving early detection of disease among pilots.

DISCUSSION: We discuss the current state of knowledge regarding the use of CACS in cardiovascular screening of military pilots and its potential to complement existing screening protocols. Finally, a diagnostic algorithm for incorporating CACS into the routine assessment of Polish Air Force pilots will be included, which may enhance the early detection of cardiac pathologies and improve flight safety.

Kurek MA, Salacinska D, Rola M, Antoniak R. Optimizing cardiovascular screening in Polish Air Force pilots with coronary artery calcium score. Aerosp Med Hum Perform. 2025; 96(5):407–413.

INTRODUCTION: Post-COVID-19, 10–20% of individuals may experience long-term symptoms (some having cognitive deficits), even after mild or nonsymptomatic infection. A sufficiently sensitive screening test of cognitive function, based on the typical cognitive effects of COVID-19 and skills considered most relevant to pilot performance, would be highly beneficial to be used alongside other performance checks. This study aimed to identify appropriate screening tests for post-COVID-19 cognitive dysfunction.

METHODS: Initially, a systematic search and narrative review identified 13 screening tools that are likely to be effective in screening pilots for post-COVID-19 neurocognitive impairment. Following a more in-depth evaluation of the identified tools, five tests including the Trail Making Test, Symbol Digit Modalities Test, Stroop Color Word Test, Psychomotor Vigilance Test, and Paced Auditory Serial Addition Test were chosen for a Delphi evaluation exercise. A two-round modified Delphi process was undertaken with international aviation medicine and psychology experts to obtain a consensus on which of the identified tests would be appropriate to screen for cognitive dysfunction in pilots.

RESULTS: Based on evaluation of literature review findings and Delphi consultation with subject matter experts, the Trail Making Test and Symbol Digit Modalities Test were identified as quick and suitable screening tests likely to detect post-COVID-19 cognitive dysfunction.

DISCUSSION: These tools are objective, have good utility, are available in multiple versions, and assess cognitive abilities relevant to pilot performance. Their use for screening in aeromedical examinations would be further supported by confirming their ability to reliably detect neurocognitive impacts associated with COVID-19.

Beka SG, Griffiths RF, Myers JA, Skirrow PM. Appropriate screening tests to assess post-COVID-19 cognitive dysfunction in aeromedical settings. Aerosp Med Hum Perform. 2025; 96(5):414–424.

INTRODUCTION: Fighter pilots endure significant physical stress due to elevated gravitational forces, leading to a high prevalence of neck pain. The biomechanical loads and operational demands of high-gravitational maneuvers highlight the need for targeted interventions. Exercise training has been proposed to mitigate neck pain and enhance musculoskeletal resilience. This review examines the effectiveness of exercise interventions and identifies research gaps requiring further exploration.

METHODS: A PRISMA-guided systematic review examined randomized controlled trials and longitudinal studies on fighter pilot neck pain exercise interventions. Databases searched included PubMed, Cochrane Library, Defense Technical Information Center, and Web of Science, with search terms such as “fighter pilot,” “aircrew,” “exercise,” “neck pain,” “cervical,” “G_z,” and “conditioning.” Two independent reviewers selected studies based on population, intervention, outcomes, and design. There were 5 studies that met the inclusion criteria, involving 199 participants.

RESULTS: The findings were mixed regarding the effectiveness of exercise interventions in reducing neck pain. Three studies reported significant pain reduction, while two found no significant changes. Programs incorporating deep cervical muscle training and supervised sessions demonstrated more consistent positive outcomes. Improvements in neck muscle strength and endurance were observed across all studies. Training compliance was higher in supervised (58–77%) than unsupervised (28–41%) programs.

DISCUSSION: Exercise interventions, particularly strength and endurance training, show the potential to improve neck muscle function in fighter pilots. However, mixed results on pain reduction, small sample sizes, and varied methodologies limit generalizability. Future research should employ standardized definitions of flight-related neck pain and robust methods to develop tailored exercise protocols.

Acevedo A, Zeigler Z. Exercise training and neck pain in fighter pilots. Aerosp Med Hum Perform. 2025; 96(5):425–430.

INTRODUCTION: Fighter pilots face unique occupational challenges, including exposure to high G-forces in suboptimal seating postures and wearing heavy equipment around neck and head. These factors contribute to a high prevalence of neck and back complaints, which can impair flight performance and prevent deployment of pilots.

METHODS: A cross-sectional survey was performed on the self-reported prevalence of neck and back pain among F-16 and F-35 pilots in the Royal Netherlands Air Force. Of the 121 pilots who were invited to participate, 50% (N = 61) were included. The questionnaire was based on prior research and adapted for military pilots. Differences between F-16 and F-35 pilots were analyzed.

RESULTS: The subjects were 36 yr (IQR 30.0–46.0) of age and had 1900 flight hours (IQR 1000–2800). We observed a statistically significant higher prevalence of back pain among F-35 pilots compared to F-16 pilots (46% vs. 8%), whereas neck pain was higher but not statistically significant among F-35 pilots (51% vs. 38%). Contributing factors included seat angle, heavy (helmet-mounted) equipment, and specific flight maneuvers. A majority (83%) reported a negative impact on flight performance, with 38% stating it affected flight safety. Suggested preventive strategies include a multidisciplinary approach as well as adjustments of equipment.

DISCUSSION: This study represents the first investigation into neck and back pain among F-35 pilots and shows a higher rate of both back and neck pain compared to F-16 pilots. Equipment and seat angle appear to be the main contributing factors. Targeted interventions are needed to prevent structural injuries, improve performance, and increase deployability.

den Bult-van Wieren GB, van Rijswijk A, Kuypers MI, Steinman Y, Wingelaar TT, Nelissen RGHH. Increase in neck and back pain in fighter pilots after the introduction of the F-35 platform. Aerosp Med Hum Perform. 2025; 96(5):431–435.

INTRODUCTION: Long-duration space missions introduce stressors that can disturb the affective states of astronauts (e.g., isolation, workload). However, studies in space or in space-analog environments struggle to find a consensus on the affective impact of these stressors. Also, there is a lack of research using multiple measures to assess affective states in these conditions (e.g., positive and negative measures and physiological parameters). More research is needed to understand the psycho-physiological mechanisms during long-duration space-like missions. Our study was conducted during a space-analog confinement (SIRIUS-19). Throughout the mission, we assessed variations of affective states using subjective and physiological parameters. We expected interindividual variability, with transitory and chronic changes on the psychological and physiological dimensions of affective states.

METHODS: Six subjects (three men/three women; four Russians/two Americans; age = 33.83 ± 6.37) performed the protocol once a month during the 4-mo confinement. Subjects completed various psychometric scales about their affective states (Self-Assessment Manikin, Positive and Negative Affective Schedule) and provided hair cortisol samples. Due to the small sample size, only individual values and descriptive statistics were used.

RESULTS: Psychometric measures remained positive and stable. Hair cortisol levels increased at the beginning of the mission (from 31.79 ± 18.05 pg · mg⁻¹ to 62.25 ± 31.99 pg · mg⁻¹). Most of the measurements showed interindividual variability.

DISCUSSION: The subjective affective states remained positive and relatively stable throughout the mission. The initial increase of hair cortisol is attributed to an adaptation phase of the crew. No affective variation seems to be related to this phase. Our results indicate effective affective adaptation to the confinement.

Pauly J, Langlet C, Hainaut J-P, Yusupova A, Bolmont B. Affective states in a space-analog mission and insights from psychometric and hair cortisol measures. Aerosp Med Hum Perform. 2025; 96(5):436–442.

BACKGROUND: Patients with lung disease can experience hypoxemia on commercial aircraft, which can usually be corrected with supplementary oxygen. In some cases, combinations of medical conditions and inability to deliver oxygen via simple methods can complicate assessment and delivery of flight oxygen.

CASE REPORT: A 53-yr-old woman with multiple comorbidities planned a 4-h commercial flight. She has end-stage obstructive lung disease, hypercapnic respiratory failure requiring home oxygen, and previous laryngeal cancer treated by total laryngectomy, resulting in a neck stoma. She is prescribed 28% oxygen therapy via a stoma Venturi mask requiring 4 L · min⁻¹. An airline-approved oxygen concentrator was necessary for flight, providing a maximum 3 L · min⁻¹, so we could not assess flight oxygen without changing the delivery method, although a direct stoma oxygen connection or the use of heat and moisture exchangers (HME) had been contraindicated for normal use. Hypoxic challenge testing with various delivery methods showed that 3 L · min⁻¹ was sufficient to maintain oxygenation safely with little risk of hypercapnia. Fitting a stoma HME with integral oxygen attachment caused accumulation of secretions and minor desaturation, although the patient could clear them spontaneously. Ultimately HME use was approved for flight only, although other methods were successfully evaluated.

DISCUSSION: Patients with respiratory conditions are often dissuaded from flying by healthcare professionals, especially in complex cases where guidelines do not address all combinations of medical conditions. With tailored assessment and advice, surgically altered airway anatomy should not preclude commercial air travel, even if supplementary oxygen is required.

Spurling KJ, Loft J, Ottun S, Moonsie I. Preparing an oxygen-dependent passenger with a surgically altered airway for commercial air travel. Aerosp Med Hum Perform. 2025; 96(5):443–446.

INTRODUCTION: Real-time monitoring of pilots through physiological responses may provide a means of identifying onset of degraded states. This could potentially be used to introduce methods of preventing negative impacts to performance. However, few studies to date have examined whether quantitative physiological data can successfully be recorded in actual flight, with even fewer during extreme maneuvering.

METHODS: An observational study was completed where physiological data was collected from three Army aviators while they completed an upset prevention and recovery training. The training was through a private company not affiliated with the Department of Defense. Subjects completed multiple flights within a small, acrobatic fixed-wing aircraft. Physiological data [electroencephalography (EEG) and electrocardiography] were recorded continuously in flight.

RESULTS: The physiological data were evaluated for signal loss and signal quality. The electrocardiography signals were determined as excellent quality based on the metrics proposed previously, with minimal signal loss. Similarly, the EEG recordings had near zero loss of data, except for one of the participant’s flights. The EEG quality was determined to be acceptable.

DISCUSSION: This study demonstrates an important step in real-time monitoring. It was demonstrated that qualitative physiological data can successfully be recorded in flight during extreme maneuvering. Further research is needed to determine the utility of such data in relation to pilot state and performance. Demonstration that this type of data can be successfully collected in flight while pilots undergo extreme maneuvers provides promise for using these types of measures across a variety of flight scenarios where a pilot’s cognitive states may become degraded.

Yue X, Andres K, Duffy MJ, Rodriguez R, Aura CJ, Feltman KA. Measuring pilot physiology during in-flight training and implications for real-time monitoring. Aerosp Med Hum Perform. 2025; 96(5):447–452.