BACKGROUND: The risks posed by flight illusions impacting pilot spatial orientation have been determined as a safety concern from numerous past aviation accident investigations. Early demonstration of the adverse effects of flight illusions on spatial orientation would be desirable for all pilots, especially at the early training stages to deeply embed good practices for onset detection, flight correction, and response mitigation.METHOD: Simulated flights on a disorientation demonstrator were performed by 19 pilots for 3 conditions: no illusion, somatogyral illusion, and Coriolis illusion. An objective approach for assessing pilot performance degradation due to flight illusions can be done by using a defined flight profile: instrument landing system (ILS) flight trajectory during final instrument approach. Deviations to the standard ILS profile were recorded to measure and evaluate the influence of the demonstrated flight illusion on pilot performance.RESULTS: The results show the expectation that the smallest deviations from the ideal trajectory are caused by pilot tracking error (no illusion), and the greatest deviations are caused by the Coriolis illusion. Results demonstrated a statistically significant effect of illusions on performance. According to statements from pilots, training for flight illusion response is essential to complement training in aircraft regulations and aerodynamics.DISCUSSION: Measuring the influence of vestibular illusions on flight profile with a simulator allows assessment of individual differences and improvement of pilot performance under the conditions of no illusion, the somatogyral illusion, and the Coriolis illusion.Boril J, Smrz V, Blasch E, Lone M. Spatial disorientation impact on the precise approach in simulated flight. Aerosp Med Hum Perform. 2020; 91(10):767775.

INTRODUCTION: Hypoxia-induced hyperventilation is an effect of acute altitude exposure, which may lead to respiratory muscle fatigue and secondary locomotor muscle fatigue. The purpose of this study was to determine if resistive and/or endurance respiratory muscle training (RRMT and ERMT, respectively) vs. placebo respiratory muscle training (PRMT) improve cycling performance at altitude.METHODS: There were 24 subjects who were assigned to PRMT (N 8), RRMT (N 8), or ERMT (N 8). Subjects cycled to exhaustion in a hypobaric chamber decompressed to 3657 m (12,000 ft) at an intensity of 55% sea level maximal oxygen consumption (Vo_2max) before and after respiratory muscle training (RMT). Additionally, subjects completed a Vo_2max, pulmonary function, and respiratory endurance test (RET) before and after RMT. All RMT protocols consisted of three 30-min training sessions per week for 4 wk.RESULTS: The RRMT group increased maximum inspiratory (P_Imax) and expiratory (P_Emax) mouth pressure after RMT (P_Imax: 117.7 11.6 vs. 162.6 20.0; P_Emax: 164.0 33.2 vs. 216.5 44.1 cmH₂O). The ERMT group increased RET after RMT (5.2 5.2 vs.18.6 16.9 min). RMT did not improve Vo_2max in any group. Both RRMT and ERMT groups increased cycling time to exhaustion (RRMT: 35.9 17.2 vs. 45.6 22.2 min and ERMT: 33.8 9.6 vs. 42.9 27.0 min).CONCLUSION: Despite different improvements in pulmonary function, 4 wk of RRMT and ERMT both improved cycle time to exhaustion at altitude.Wheelock CE, Hess HW, Johnson BD, Schlader ZJ, Clemency BM, St. James E, Hostler D. Endurance and resistance respiratory muscle training and aerobic exercise performance in hypobaric hypoxia. Aerosp Med Hum Perform. 2020; 91(10):776784.

INTRODUCTION: We compared the physiological responses, psychomotor performances, and hypoxia symptoms between 7000 m and 7500 m (23,000 and 24,600 ft) exposure to develop a safer hypoxia training protocol.METHODS: In altitude chamber, 66 male pilots were exposed to 7000 and 7500 m. Heart rate and arterial oxygen saturation were continuously monitored. Psychomotor performance was assessed using the computational task. The hypoxic symptoms were investigated by a questionnaire.RESULTS: The mean duration time of hypoxia was 323.0 56.5 s at 7000 m and 218.2 63.3 s at 7500 m. The 6-min hypoxia training was completed by 57.6% of the pilots and 6.1% of the pilots at 7000 m and at 7500 m, respectively. There were no significant differences in pilots heart rates and psychomotor performance between the two exposures. The S_po₂ response at 7500 m was slightly severer than that at 7000 m. During the 7000 m exposure, pilots experienced almost the same symptoms and similar frequency order as those during the 7500 m exposure.CONCLUSIONS: There were concordant symptoms, psychomotor performance, and very similar physiological responses between 7000 m and 7500 m during hypoxia training. The results indicated that 7000-m hypoxia awareness training might be an alternative to 7500-m hypoxia training with lower DCS risk and longer experience time.Wen D, Tu L, Wang G, Gu Z, Shi W, Liu X. Psychophysiological responses of pilots in hypoxia training at 7000 and 7500 m. Aerosp Med Hum Perform. 2020; 91(10):785789.

BACKGROUND: Flight-associated neck pain (FANP) is a serious problem in fighter pilots. Despite the high impact of FANP there is little evidence for effective management. However, self-kinematic training showed a positive effect in the general population. The purpose of this study was to investigate the effectiveness of a self-kinematic training program using virtual reality in improving neck pain in fighter pilots.METHODS: There were 45 pilots with FANP who were randomized to a control group (N 23) or a training group (N 22). Training participants were instructed to exercise using a personalized self-training program, for 20 min/wk, for 4 wk. Primary outcome measures were neck disability (NDI%) and mean velocity ( s¹), and secondary were pain, health status, accuracy, and isometric strength. Assessments were conducted by a blinded assessor and intention-to-treat analysis by a blinded statistician.RESULTS: There were 40 pilots who completed the postintervention assessments, and 35 completed the 6-mo follow-up. Baseline measurements showed mild pain and disability (mean VAS 43 22.73, NDI 17.76 9.59%) and high kinematic performance. Compliance with self-training was poor. No differences were observed in self-reported measures and strength. Exercise duration was correlated with NDI% improvement.DISCUSSION: This self-kinematic training promoted kinematic performance, but was ineffective in engaging the pilots to exercise, and consequently did not improve pain and disability. Poor compliance was previously reported in self-training for FANP, suggesting further studies should prioritize supervised training. Considering the high baseline kinematic performance, kinematics does not seem to be a key factor in FANP, and future exercise research should aim for intense strengthening to increase endurance to the high G_z pilots experience.Sarig Bahat H, German D, Palomo G, Gold H, Frankel Nir Y. Self-kinematic training for flight-associated neck pain: a randomized controlled trial. Aerosp Med Hum Perform. 2020; 91(10):790797.

BACKGROUND: Piloting an aircraft is a complex cognitive task. Human error represents a major contributing factor in aviation accidents. Emotion plays an important role in aviation safety. We performed a functional magnetic resonance imaging (fMRI) study to explore whether pilots and nonpilots may differ in the neural mechanisms responsible for the processing of conflict emotional information.METHODS: A total of 27 civil aviation pilots and 24 nonpilot controls performed the emotional Stroop task, in which participants were required to identify the facial expressions of the stimuli while ignoring the congruent or incongruent emotional words superimposed on the faces. Neural responses to the stimuli were compared between pilots and controls. Also, a psychophysiological interaction (PPI) analysis was performed to explore whether there were differences in effective connectivity between pilots and nonpilots.RESULTS: Behavioral data showed that pilots (21.23 ms) and nonpilots (26.78 ms) had equivalent congruency effects. Nevertheless, their neural activation patterns differed. Compared with pilots, nonpilots exhibited neural activity in the right supramarginal gyrus when processing incongruent stimuli, and more regions were activated in the process of conflict monitoring. The PPI analysis showed greater activity between the right supramarginal gyrus and the right lingual gyrus when nonpilots confronted incongruent vs. congruent stimuli. However, this effective connectivity was not found in pilots.CONCLUSION: These results suggest different mechanisms underlying emotional conflict control between pilots and the general population.Jiang H, Xu K, Chen X, Wang Q, Yang Y, Fu C, Guo X, Chen X, Yang J. The neural underpinnings of emotional conflict control in pilots. Aerosp Med Hum Perform. 2020; 91(10):798805.

BACKGROUND: Scuba diving activities expose divers to serious accidents, which can require early hospitalization. Helicopters are used for early evacuation. On the French Mediterranean coast, rescue is made offshore mainly by a French Navy Dauphin or at a landing zone by an emergency unit EC 135 helicopter.METHODS: We retrospectively analyzed diving accidents evacuated by helicopter on the French Mediterranean coast from 1 September 2014 to 31 August 2016. We gathered data at the Center for Hyperbaric Medicine and Diving Expertise (SMHEP) of the Sainte-Anne Military Hospital (Toulon, France), the 35 F squadron at Hyres (France) Naval Air Station, and the SAMU 83 emergency unit (Toulon, France).RESULTS: A total of 23 diving accidents were evacuated offshore by Dauphin helicopter and 23 at a landing zone on the coast by EC 135 helicopter without hoist. Immersion pulmonary edema (IPE) accounted for one-third of the total diving accidents evacuated by helicopter with identified causes. It was responsible for at least half of the deaths at the dive place. A quarter of the rescued IPE victims died because of early cardiac arrest.DISCUSSION: Helicopter evacuation is indicated when vital prognosis (IPE and pulmonary overpressure in particular) or neurological functional prognosis (decompression sickness) is of concern. IPE is the primary etiology in patients with serious dive injuries that are life-threatening and who will benefit from helicopter evacuation. A non-invasive ventilation device with inspiratory support and positive expiratory pressure must be used, in particular for IPE.Corgie L, Huiban N, Pontier J-M, Brocq F-X, Boulard J-F, Monteil M. Diving accident evacuations by helicopter and immersion pulmonary edema. Aerosp Med Hum Perform. 2020; 91(10):806811.

BACKGROUND: The increased utility of CT coronary angiography (CTCA) in cardiovascular screenings of aircrew has led to the increased detection of asymptomatic coronary artery disease (CAD). A systematic review of studies relevant to the interpretation of CTCA for the occupational fitness assessment of high-risk vocations was performed, with findings used to describe the development of a pathway for the aeromedical disposition of military aviators with asymptomatic CAD.METHODS: Medline was searched using the terms CT coronary angiogram and screening and prognosis. The inclusion criteria were restricted to study populations ages > 18 yr, were asymptomatic, were not known to have CAD, had undergone CTCA, and with their associations with major adverse cardiovascular events (MACE) and other relevant cardiac outcomes reported.RESULTS: Included in this systematic review were 10 studies. When compared to subjects with no or nonobstructive CAD, those with obstructive CAD on CTCA had hazard ratios (HR) for cardiac events ranging from 1.42 to 105.48. Comparing subjects with nonobstructive CAD and those without CAD on CTCA, a lower HR of 1.19 for cardiac events was found. The annual event rates of subjects with no CAD on CTCA were extremely low, ranging from 0 to 0.5%.CONCLUSIONS: Based on the findings, we suggest that CTCA should only be performed in aircrew with higher cardiac risk profiles. Those found to have no CAD or minimal CAD (i.e., 25% stenosis) in a non-left main coronary artery on CTCA can be returned to flying duties. All other results should be further evaluated with an invasive angiogram.Cheong RWL, See B, Tan BBC, Koh CH. Coronary artery disease screening using CT coronary angiography. Aerosp Med Hum Perform. 2020; 91(10):812817.

INTRODUCTION: Due to the standard collegiate academic calendar (two semesters), U.S. Air Force Reserve Officers Training Corps (ROTC) cadets have an approximate 3-mo break over the summer in which physical training (PT) is neither regulated nor required. The purpose of this investigation was to determine if significant changes in cadet physical fitness assessment (PFA) scores occur after a 3-mo summer break when training is not mandatory.METHODS: Male (N 28) and female (N 10) cadets performed the PFA in April and August. Cadets were split into two groups depending on if they participated in field training over the summer [FT; N 12 (men 6, women 6)] or did not [NFT; N 26 (men 22, women 4)] to determine if engaging in field training had any effect on performance.RESULTS: Cadets performed significantly better on run time (7%), pushups (7.6%), sit-ups (5.8%), and overall composite score (3.6%) before summer break compared to after. Significant time group interactions were observed for abdominal circumference and run time. Abdominal circumference paired samples t-tests indicated that while the FT group did not differ between the spring and fall time points, the NFT did. There was a main effect for time in which cadets had a significantly larger abdominal circumference in the spring compared to the fall semester.CONCLUSION: Nonmandatory physical training over summer break may significantly decrease a cadets performance on the PFA. Additionally, it appears that even the inclusion of field training for some cadets was not enough to prevent the detraining that took place over summer break.Mackey CS, Johnson Q, Dawes JJ, DeFreitas JM. Physical performance among Air Force ROTC cadets following non-mandatory training. Aerosp Med Hum Perform. 2020; 91(10):818823.

BACKGROUND: Frequent migraine headaches are disabling and aeromedically disqualifying. Four new monoclonal antibody medications, targeting calcitonin gene-related peptide (CGRP), have been approved by the U.S. Food and Drug Administration (FDA) since 2018, with more expected in the coming years. These medications present new alternatives for the treatment of migraine unresponsive to other therapeutic and prophylactic agents.CASE REPORT: We present a case of a 45-yr-old commercial pilot who presented with migraine headaches increasing in frequency to 1315 per month in spite of the use of propranolol for prophylaxis and sumatriptan for abortive treatment of the headaches. Upon presentation, he was not flying due to his frequent headaches and he was started on monthly subcutaneous injections of fremanezumab. Following his second injection, his headaches stopped entirely, and he has continued on the medication and not experienced another migraine headache. He underwent an aeromedical neurology evaluation and consideration for Authorization of Special Issuance of Medical Certificate, which was granted by the Federal Aviation Administration (FAA).DISCUSSION: This is the first case to our knowledge of the successful use of an anti-CGRP monoclonal antibody medication in an active pilot. The pilot appears to be a super responder to the medication, having achieved complete remission of a nearly life-long condition. Though only a small portion of treated individuals will see this sort of response, these medications represent an effective additional option for migraine prophylaxis in the pilot population.Garber MA, Sirven JI, Roth RS, Hemphill JM. Migraine prophylaxis using novel monoclonal antibody injections in a commercial pilot. Aerosp Med Hum Perform. 2020; 91(10):824825.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem involvement. Clinical management of this condition has unique aeromedical considerations and an impact on subsequent aeromedical disposition. A comprehensive decision matrix would greatly benefit aviation medicine practitioners in the management of aircrew and personnel in flying-related vocations who are diagnosed with SLE.CASE REPORT: We describe the aeromedical management of a military air traffic controller who was diagnosed with SLE after presenting with cutaneous lupus, nonscarring alopecia, symmetrical small joint polyarthropathy, leukopenia, and presence of SLE-specific antibody. She was treated with hydroxychloroquine and low-dose systemic glucocorticoids, and allowed to return to duties with a proximity restriction and a bar on field deployments and night duties.DISCUSSION: Several SLE manifestations may have either incapacitating or distracting effects on aircrew and personnel in flying-related vocations. Some medications used in the treatment of SLE may similarly impact on an individuals ability to safely execute flight or air traffic control duties. We propose an aeromedical disposition decision flowchart that would guide aviation medicine practitioners in the management of individuals diagnosed with SLE to ensure optimal and safe performance in their respective occupational settings.Seah BZQ, Chua CG. A proposed aeromedical disposition flowchart for systemic lupus erythematosus. Aerosp Med Hum Perform. 2020; 91(10):826832.