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Secondary progressive MS occurs in around 65% of those with initial relapsing-remitting MS, who eventually have progressive neurologic decline between acute attacks without any definite periods of remission. Occasional relapses and minor remissions may appear. The most common length of time between disease onset and conversion from relapsing-remitting to secondary progressive MS is 19 years.
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Independently of the types published by the MS associations, regulatory agencies like the FDA often consider special courses, trying to reflect some clinical trials results on their approval documents. Some examples could be "Highly Active MS" (HAMS), "Active Secondary MS" (similar to the old Progressive-Relapsing) and "Rapidly progressing PPMS".
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Also, when deficits always resolve between attacks, this is sometimes referred to as "benign MS", although people will still build up some degree of disability in the long term. On the other hand, the term "malignant multiple sclerosis" is used to describe people with MS having reached significant level of disability in a short period.
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Atypical variants of MS have been described; these include tumefactive multiple sclerosis, Balo concentric sclerosis, Schilder's diffuse sclerosis, and Marburg multiple sclerosis. There is debate on whether they are MS variants or different diseases. Some diseases previously considered MS variants like Devic's disease are now considered outside the MS spectrum.
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Although there is no known cure for multiple sclerosis, several therapies have proven helpful. Several effective treatments can significantly decrease the number of attacks and the rate of progression. The primary aims of therapy are returning function after an attack, preventing new attacks, and preventing disability. Starting medications is generally recommended in people after the first attack when more than two lesions are seen on MRI.
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Older medications used to treat MS were modestly effective, could have side effects, and were poorly tolerated. However, several treatment options with better safety and tolerability profiles have been introduced, changing the prognosis of MS. In the treatment era, 16% of people with relapsing MS went on to need a cane to walk after 20 years.
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As with any medical treatment, medications used in the management of MS have several adverse effects. Alternative treatments are pursued by some people, despite the shortage of supporting evidence of efficacy.
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During symptomatic attacks, administration of high doses of intravenous corticosteroids, such as methylprednisolone, is the usual therapy, with oral corticosteroids seeming to have a similar efficacy and safety profile. Although effective in the short term for relieving symptoms, corticosteroid treatments do not appear to have a significant impact on long-term recovery. The long-term benefit is unclear in optic neuritis as of 2020. The consequences of severe attacks that do not respond to corticosteroids might be treatable by plasmapheresis.
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As of 2021, multiple disease-modifying medications were approved by regulatory agencies for relapsing-remitting multiple sclerosis (RRMS). In RRMS they are modestly effective at decreasing the number of attacks. The interferons and glatiramer acetate are first-line treatments and are roughly equivalent, reducing relapses by approximately 30%. Early-initiated long-term therapy is safe and improves outcomes.
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Treatment of clinically isolated syndrome (CIS) with interferons decreases the chance of progressing to clinical MS. Efficacy of interferons and glatiramer acetate in children has been estimated to be roughly equivalent to that of adults. The role of some newer agents such as fingolimod, teriflunomide, and dimethyl fumarate, is not yet entirely clear. It is difficult to make firm conclusions about the best treatment, especially regarding the long‐term benefit and safety of early treatment, given the lack of studies directly comparing disease modifying therapies or long-term monitoring of patient outcomes.
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The relative effectiveness of different treatments is unclear, as most have only been compared to placebo or a small number of other therapies. Direct comparisons of interferons and glatiramer acetate indicate similar effects or only small differences in effects on relapse rate, disease progression and magnetic resonance imaging measures. Alemtuzumab, natalizumab, and fingolimod may be more effective than other drugs in reducing relapses over the short term in people with RRMS. Natalizumab and interferon beta-1a (Rebif) may reduce relapses compared to both placebo and interferon beta-1a (Avonex) while Interferon beta-1b (Betaseron), glatiramer acetate, and mitoxantrone may also prevent relapses. Evidence on relative effectiveness in reducing disability progression is unclear. All medications are associated with adverse effects that may influence their risk to benefit profiles.
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, only one medication, mitoxantrone, had been approved for secondary progressive MS. In this population tentative evidence supports mitoxantrone moderately slowing the progression of the disease and decreasing rates of relapses over two years.
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As of 2013, review of 9 immunomodulators and immunosuppressants found no evidence of any being effective in preventing disability progression in people with progressive MS.
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In March 2017 the FDA approved ocrelizumab as a treatment for primary progressive MS in adults, the first drug to gain that approval, with requirements for several Phase IV clinical trials. It is also used for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults.
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In 2019, siponimod and cladribine were approved in the United States for the treatment of secondary progressive multiple sclerosis.
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The disease-modifying treatments have several adverse effects. One of the most common is irritation at the injection site for glatiramer acetate and the interferons (up to 90% with subcutaneous injections and 33% with intramuscular injections). Over time, a visible dent at the injection site, due to the local destruction of fat tissue, known as lipoatrophy, may develop. Interferons may produce flu-like symptoms; some people taking glatiramer experience a post-injection reaction with flushing, chest tightness, heart palpitations, and anxiety, which usually lasts less than thirty minutes. More dangerous but much less common are liver damage from interferons, systolic dysfunction (12%), infertility, and acute myeloid leukemia (0.8%) from mitoxantrone, and progressive multifocal leukoencephalopathy occurring with natalizumab (occurring in 1 in 600 people treated).
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Fingolimod may give rise to hypertension and slowed heart rate, macular edema, elevated liver enzymes, or a reduction in lymphocyte levels. Tentative evidence supports the short-term safety of teriflunomide, with common side effects including: headaches, fatigue, nausea, hair loss, and limb pain. There have also been reports of liver failure and PML with its use and it is dangerous for fetal development. Most common side effects of dimethyl fumarate are flushing and gastrointestinal problems. While dimethyl fumarate may lead to a reduction in the white blood cell count there were no reported cases of opportunistic infections during trials.
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Both medications and neurorehabilitation have been shown to improve some symptoms, though neither changes the course of the disease. Some symptoms have a good response to medication, such as bladder spasticity, while others are little changed. Equipment such as catheters for neurogenic bladder or mobility aids can be helpful in improving functional status.
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A multidisciplinary approach is important for improving quality of life; however, it is difficult to specify a 'core team' as many health services may be needed at different points in time. Multidisciplinary rehabilitation programs increase activity and participation of people with MS but do not influence impairment level. Studies investigating information provision in support of patient understanding and participation suggest that while interventions (written information, decision aids, coaching, educational programmes) may increase knowledge, the evidence of an effect on decision making and quality of life is mixed and low certainty. There is limited evidence for the overall efficacy of individual therapeutic disciplines, though there is good evidence that specific approaches, such as exercise, and psychological therapies are effective. Cognitive training, alone or combined with other neuropsychological interventions, may show positive effects for memory and attention though firm conclusions are not possible given small sample numbers, variable methodology, interventions and outcome measures. The effectiveness of palliative approaches in addition to standard care is uncertain, due to lack of evidence. The effectiveness of interventions, including exercise, specifically for the prevention of falls in people with MS is uncertain, while there is some evidence of an effect on balance function and mobility. Cognitive behavioral therapy has shown to be moderately effective for reducing MS fatigue. The evidence for the effectiveness of non-pharmacological interventions for chronic pain is insufficient to recommend such interventions alone, however their use in combination with medications may be reasonable.
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The spasticity associated with MS can be difficult to manage because of the progressive and fluctuating course of the disease. Although there is no firm conclusion on the efficacy in reducing spasticity, PT interventions can be a safe and beneficial option for patients with multiple sclerosis. Physical therapy including vibration interventions, electrical stimulation, exercise therapy, standing therapy, and radial shock wave therapy (RSWT), were beneficial for limiting spasticity, helping limit excitability, or increasing range of motion.
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Over 50% of people with MS may use complementary and alternative medicine, although percentages vary depending on how alternative medicine is defined. Regarding the characteristics of users, they are more frequently women, have had MS for a longer time, tend to be more disabled and have lower levels of satisfaction with conventional healthcare. The evidence for the effectiveness for such treatments in most cases is weak or absent. Treatments of unproven benefit used by people with MS include dietary supplementation and regimens, vitamin D, relaxation techniques such as yoga, herbal medicine (including medical cannabis), hyperbaric oxygen therapy, self-infection with hookworms, reflexology, acupuncture, and mindfulness. Evidence suggests vitamin D supplementation, irrespective of the form and dose, provides no benefit for people with MS; this includes for measures such as relapse recurrence, disability, and MRI lesions while effects on health‐related quality of life and fatigue are unclear. There is insufficient evidence supporting high-dose biotin and some evidence for increased disease activity and higher risk of relapse with its use.
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The availability of treatments that modify the course of multiple sclerosis beginning in the 1990s, known as disease-modifying therapies (DMTs), has improved prognosis. These treatments can reduce relapses and slow progression, but as of 2022 there is no cure.
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The prognosis of MS depends on the subtype of the disease, and there is also great individual variation in the progression of the disease. For relapsing MS, which is the most common subtype, approximately one of every five people later transition to secondary progressive MS, a form characterized by more progressive decline. A 2016 cohort study found that after a median of 16.8 years from onset, one in ten of those with relapsing MS needed a walking aid, and almost two in ten transitioned to secondary progressive MS. With treatments available in the 2020s, relapses can be eliminated or substantially reduced. However, "silent progression" of the disease still occurs.
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In addition to secondary progressive MS (SPMS), a small proportion of people with MS (10-15%) experience progressive decline from the onset, known as primary progressive MS (PPMS). Most treatments have been approved for use in relapsing MS; there are limited effective treatments for progressive forms of MS, and treatments aren't as effective. The prognosis for progressive MS is worse, with faster accumulation of disability, though the rate of decline varies considerably between people. In untreated PPMS, the median time from onset to requiring a walking aid is estimated as seven years. In SPMS, a 2014 cohort study reported that people required a walking aid after an average of five years from onset of SPMS, and were chair or bedbound after average fifteen years.
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After diagnosis of MS, characteristics that predict a worse course are male sex, older age, and greater disability at the time of diagnosis. Female sex, though, is associated with a higher relapse rate. As of 2018, no biomarker can accurately predict disease progression in every patient. Spinal cord lesions, abnormalities on MRI, and more brain atrophy are predictive of a worse course, though brain atrophy as a predictor of disease course is experimental and not used in clinical practice as of 2018. Early treatment leads to a better prognosis, but a higher relapse frequency when treated with DMTs is associated with a poorer prognosis.
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MS is the most common autoimmune disorder of the central nervous system. As of 2022, there are nearly one million known cases of multiple sclerosis in the United States. In 2020, the number of people with MS was 2.8 million globally, with rates varying widely in different regions. In Africa rates are less than 0.5 per 100,000, while they are 2.8 per 100,000 in South East Asia, 8.3 per 100,000 in the Americas, and 80 per 100,000 in Europe. Rates surpass 200 per 100,000 in certain populations of Northern European descent. The number of new cases that develop per year is about 2.5 per 100,000.
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Increasing rates of MS may be explained simply by better diagnosis. Studies on populational and geographical patterns have been common and have led to a number of theories about the cause.
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MS usually appears in adults in their late twenties or early thirties but it can rarely start in childhood and after 50 years of age. The primary progressive subtype is more common in people in their fifties. Similarly to many autoimmune disorders, the disease is more common in women, and the trend may be increasing. As of 2008, globally it is about two times more common in women than in men. In children, it is even more common in females than males, while in people over fifty, it affects males and females almost equally.
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Robert Carswell (1793–1857), a British professor of pathology, and Jean Cruveilhier (1791–1873), a French professor of pathologic anatomy, described and illustrated many of the disease's clinical details, but did not identify it as a separate disease. Specifically, Carswell described the injuries he found as "a remarkable lesion of the spinal cord accompanied with atrophy". Under the microscope, Swiss pathologist Georg Eduard Rindfleisch (1836–1908) noted in 1863 that the inflammation-associated lesions were distributed around blood vessels.
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The French neurologist Jean-Martin Charcot (1825–1893) was the first person to recognize multiple sclerosis as a distinct disease in 1868. Summarizing previous reports and adding his own clinical and pathological observations, Charcot called the disease "sclerose en plaques".
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The first attempt to establish a set of diagnostic criteria was also due to Charcot in 1868. He published what now is known as the "Charcot Triad", consisting in nystagmus, intention tremor, and telegraphic speech (scanning speech). Charcot also observed cognition changes, describing his patients as having a "marked enfeeblement of the memory" and "conceptions that formed slowly".
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Diagnosis was based on Charcot triad and clinical observation until Schumacher made the first attempt to standardize criteria in 1965 by introducing some fundamental requirements: Dissemination of the lesions in time (DIT) and space (DIS), and that "signs and symptoms cannot be explained better by another disease process". The DIT and DIS requirement was later inherited by Poser criteria and McDonald criteria, whose 2017 revision is in use.
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During the 20th century, theories about the cause and pathogenesis were developed and effective treatments began to appear in the 1990s. Since the beginning of the 21st century, refinements of the concepts have taken place. The 2010 revision of the McDonald criteria allowed for the diagnosis of MS with only one proved lesion (CIS).
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In 1996, the US National Multiple Sclerosis Society (NMSS) (Advisory Committee on Clinical Trials) defined the first version of the clinical phenotypes that is in use. In this first version they provided standardized definitions for four MS clinical courses: relapsing-remitting (RR), secondary progressive (SP), primary progressive (PP), and progressive relapsing (PR). In 2010, PR was dropped and CIS was incorporated. Three years later, the 2013 revision of the "phenotypes for the disease course" were forced to consider CIS as one of the phenotypes of MS, making obsolete some expressions like "conversion from CIS to MS". Other organizations have proposed later new clinical phenotypes, like HAMS (Highly Active MS).
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There are several historical accounts of people who probably had MS and lived before or shortly after the disease was described by Charcot.
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A young woman called Halldora who lived in Iceland around 1200 suddenly lost her vision and mobility but recovered them seven days after. Saint Lidwina of Schiedam (1380–1433), a Dutch nun, may be one of the first clearly identifiable people with MS. From the age of 16 until her death at 53, she had intermittent pain, weakness of the legs and vision loss: symptoms typical of MS. Both cases have led to the proposal of a "Viking gene" hypothesis for the dissemination of the disease.
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Augustus Frederick d'Este (1794–1848), son of Prince Augustus Frederick, Duke of Sussex and Lady Augusta Murray and a grandson of George III of the United Kingdom, almost certainly had MS. D'Este left a detailed diary describing his 22 years living with the disease. His diary began in 1822 and ended in 1846, although it remained unknown until 1948. His symptoms began at age 28 with a sudden transient visual loss (amaurosis fugax) after the funeral of a friend. During his disease, he developed weakness of the legs, clumsiness of the hands, numbness, dizziness, bladder disturbance and erectile dysfunction. In 1844, he began to use a wheelchair. Despite his illness, he kept an optimistic view of life. Another early account of MS was kept by the British diarist W. N. P. Barbellion, pen name of Bruce Frederick Cummings (1889–1919), who maintained a detailed log of his diagnosis and struggle. His diary was published in 1919 as "The Journal of a Disappointed Man".
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As of 2022, the pathogenesis of MS as it relates to EBV is actively investigated, as are disease-modifying therapies; understanding of how risk factors combine with EBV to initiate MS is sought. Whether EBV is the only cause of MS might be better understood if an EBV vaccine is developed and shown to prevent MS as well.
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Medications that influence voltage-gated sodium ion channels are under investigation as a potential neuroprotective strategy because of hypothesized role of sodium in the pathological process leading to axonal injury and accumulating disability. There is insufficient evidence of an effect of sodium channel blockers for people with MS.
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MS is a clinically defined entity with several atypical presentations. Some auto-antibodies have been found in atypical MS cases, giving birth to separate disease families and restricting the previously wider concept of MS.
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Anti-AQP4 autoantibodies were found in neuromyelitis optica (NMO), which was previously considered a MS variant. A spectrum of diseases named NMOSD (NMO spectrum diseases) or anti-AQP4 diseases has been accepted. Some cases of MS were presenting anti-MOG autoantibodies, mainly overlapping with the Marburg variant. Anti-MOG autoantibodies were found to be also present in ADEM, and a second spectrum of separated diseases is being considered. This spectrum is named inconsistently across different authors, but it is normally something similar to anti-MOG demyelinating diseases.
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A third kind of auto-antibodies is accepted. They are several anti-neurofascin auto-antibodies which damage the Ranvier nodes of the neurons. These antibodies are more related to the peripheral nervous demyelination, but they were also found in chronic progressive PPMS and combined central and peripheral demyelination (CCPD, which is considered another atypical MS presentation).
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In addition to the significance of auto-antibodies in MS, four different patterns of demyelination have been reported, opening the door to consider MS as a heterogeneous disease.
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Since disease progression is the result of degeneration of neurons, the roles of proteins showing loss of nerve tissue such as neurofilaments, tau, and N-acetylaspartate are under investigation.
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Improvement in neuroimaging techniques such as positron emission tomography (PET) or magnetic resonance imaging (MRI) carry a promise for better diagnosis and prognosis predictions. Regarding MRI, there are several techniques that have already shown some usefulness in research settings and could be introduced into clinical practice, such as double-inversion recovery sequences, magnetization transfer, diffusion tensor, and functional magnetic resonance imaging. These techniques are more specific for the disease than existing ones, but still lack some standardization of acquisition protocols and the creation of normative values. This is particularly the case for proton magnetic resonance spectroscopy, for which a number of methodological variations observed in the literature may underlie continued inconsistencies in central nervous system metabolic abnormalities, particularly in N-acetyl aspartate, myoinositol, choline, glutamate, GABA, and GSH, observed for multiple sclerosis and its subtypes. There are other techniques under development that include contrast agents capable of measuring levels of peripheral macrophages, inflammation, or neuronal dysfunction, and techniques that measure iron deposition that could serve to determine the role of this feature in MS, or that of cerebral perfusion.
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The hospitalization rate was found to be higher among individuals with MS and COVID-19 infection, at 10%, while the pooled infection rate is estimated at 4%. The pooled prevalence of death in hospitalized individuals with MS is estimated as 4%.
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One emerging hypothesis, referred to as the hygiene hypothesis, suggests that early-life exposure to infectious agents helps to develop the immune system and reduces susceptibility to allergies and autoimmune disorders, including MS. Germ-free mice infected with transplanted fecal matter from MS patients exhibit an increased risk of developing EAE, an animal model of MS. It has also been proposed that certain bacteria found in the gut use molecular mimicry to infiltrate the brain via the gut-brain axis, initiating an inflammatory response and increasing blood-brain barrier permeability. Vitamin D levels have also been correlated with MS; lower levels of vitamin D correspond to an increased risk of MS, suggesting a reduced prevalence in the tropics - an area with more Vitamin D-rich sunlight - strengthening the impact of geographical location on MS development. MS mechanisms begin when peripheral autoreactive effector CD4+ T cells get activated and move into the CNS. Antigen-presenting cells localize the reactivation of autoreactive effector CD4-T cells once they have entered the CNS, attracting more T cells and macrophages to form the inflammatory lesion. In MS patients, macrophages and microglia assemble at locations where demyelination and neurodegeneration are actively occurring, and microglial activation is more apparent in the normal-appearing white matter of MS patients. Astrocytes generate neurotoxic chemicals like nitric oxide and TNFα, attract neurotoxic inflammatory monocytes to the CNS, and are responsible for astrogliosis, the scarring that prevents the spread of neuroinflammation and kills neurons inside the scarred area.
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The Fairchild Republic A-10 Thunderbolt II is a single-seat, twin-turbofan, straight-wing, subsonic attack aircraft developed by Fairchild Republic for the United States Air Force (USAF). In service since 1976, it is named for the Republic P-47 Thunderbolt, a World War II-era fighter-bomber effective at attacking ground targets, but commonly referred to as the "Warthog" or "Hog". The A-10 was designed to provide close air support (CAS) to friendly ground troops by attacking armored vehicles, tanks, and other enemy ground forces; it is the only production-built aircraft designed solely for CAS to have served with the U.S. Air Force. Its secondary mission is to direct other aircraft in attacks on ground targets, a role called forward air controller-airborne; aircraft used primarily in this role are designated OA-10.
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The A-10 was intended to improve on the performance and firepower of the Douglas A-1 Skyraider. Its airframe was designed for durability, with measures such as of titanium armor to protect the cockpit and aircraft systems, enabling it to absorb damage and continue flying. Its ability to take off and land from relatively short runways permits operation from airstrips close to the front lines, and its simple design enables maintenance with minimal facilities.
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The A-10 served in the Gulf War (Operation Desert Storm), the American–led intervention against Iraq's invasion of Kuwait, where the aircraft distinguished itself. The A-10 also participated in other conflicts such as in Grenada, the Balkans, Afghanistan, Iraq, and against the Islamic State in the Middle East.
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The A-10A single-seat variant was the only version produced, though one pre-production airframe was modified into the YA-10B twin-seat prototype to test an all-weather night-capable version. In 2005, a program was started to upgrade the remaining A-10A aircraft to the A-10C configuration, with modern avionics for use with precision weaponry. The U.S. Air Force had stated the Lockheed Martin F-35 Lightning II would replace the A-10 as it entered service, but this remains highly contentious within the USAF and in political circles. With a variety of upgrades and wing replacements, the A-10's service life can be extended to 2040; the service has no planned retirement date .
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The development of conventionally armed attack aircraft in the United States stagnated after World War II, as design efforts for tactical aircraft focused on the delivery of nuclear weapons using high-speed designs like the McDonnell F-101 Voodoo and Republic F-105 Thunderchief. As the U.S. military entered the Vietnam War, its main ground-attack aircraft was the Korean War-era Douglas A-1 Skyraider. A capable aircraft for its era, with a relatively large payload and long loiter time, the propeller-driven design was relatively slow and vulnerable to ground fire. The U.S. Air Force and Navy lost 266 A-1s in action in Vietnam, largely from small-arms fire. The A-1 Skyraider also had poor firepower.
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The lack of modern conventional attack capability prompted calls for a specialized attack aircraft. On 7 June 1961, the Secretary of Defense Robert McNamara ordered the USAF to develop two tactical aircraft, one for the long-range strike and interdictor role, and the other focusing on the fighter-bomber mission. The former was the Tactical Fighter Experimental (TFX) intended to be common design for the USAF and the US Navy, which emerged as the General Dynamics F-111 Aardvark, while the second was filled by a version of the U.S. Navy's McDonnell Douglas F-4 Phantom II. While the Phantom went on to be one of the most successful fighter designs of the 1960s and proved to be a capable fighter-bomber, its lack of loiter time was a major problem, and to a lesser extent, its poor low-speed performance. It was also expensive to buy and operate, with a flyaway cost of $2 million in FY1965 ($ million today), and operational costs over $900 per hour ($ per hour today).
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After a broad review of its tactical force structure, the U.S. Air Force decided to adopt a low-cost aircraft to supplement the F-4 and F-111. It first focused on the Northrop F-5, which had air-to-air capability. A 1965 cost-effectiveness study shifted the focus from the F-5 to the less expensive A-7D variant of the LTV A-7 Corsair II, and a contract was awarded. However, this aircraft doubled in cost with demands for an upgraded engine and new avionics.
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During this period, the United States Army had been introducing the Bell UH-1 Iroquois into service. First used in its intended role as a transport, it was soon modified in the field to carry more machine guns in what became known as the helicopter gunship role. This proved effective against the lightly armed enemy, and new gun and rocket pods were added. Soon the Bell AH-1 Cobra was introduced. This was an attack helicopter armed with long-range BGM-71 TOW missiles able to destroy tanks from outside the range of defensive fire. The helicopter was effective and prompted the U.S. military to change its defensive strategy in Europe into blunting any Warsaw Pact advance with anti-tank helicopters instead of the tactical nuclear weapons that had been the basis for NATO's battle plans since the 1950s.
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The Cobra was a quickly-made helicopter based on the UH-1 Iroquois and was introduced in the mid-1960s as an interim design until the U.S. Army "Advanced Aerial Fire Support System" program delivered. The Army selected the Lockheed AH-56 Cheyenne, a much more capable attack aircraft with greater speed for initial production. These developments worried the USAF, which saw the anti-tank helicopter overtaking its nuclear-armed tactical aircraft as the primary anti-armor force in Europe. A 1966 Air Force study of existing close air support (CAS) capabilities revealed gaps in the escort and fire suppression roles, which the Cheyenne could fill. The study concluded that the service should acquire a simple, inexpensive, dedicated CAS aircraft at least as capable as the A-1, and that it should develop doctrine, tactics, and procedures for such aircraft to accomplish the missions for which the attack helicopters were provided.
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On 8 September 1966, General John P. McConnell, Chief of Staff of the USAF, ordered that a specialized CAS aircraft be designed, developed, and obtained. On 22 December, a Requirements Action Directive was issued for the A-X CAS airplane, and the Attack Experimental (A-X) program office was formed. On 6 March 1967, the Air Force released a request for information to 21 defense contractors for the A-X.
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In May 1970, the USAF issued a modified, more detailed request for proposals for the aircraft. The threat of Soviet armored forces and all-weather attack operations had become more serious. The requirements now included that the aircraft would be designed specifically for the 30 mm rotary cannon. The RFP also specified a maximum speed of , takeoff distance of , external load of , mission radius, and a unit cost of US$1.4 million ($ million today). The A-X would be the first USAF aircraft designed exclusively for close air support. During this time, a separate RFP was released for A-X's 30 mm cannon with requirements for a high rate of fire (4,000 round per minute) and a high muzzle velocity. Six companies submitted aircraft proposals, with Northrop and Fairchild Republic selected to build prototypes: the YA-9A and YA-10A, respectively. General Electric and Philco-Ford were selected to build and test GAU-8 cannon prototypes.
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Two YA-10 prototypes were built in the Republic factory in Farmingdale, New York, and first flown on 10 May 1972 by pilot Howard "Sam" Nelson. Production A-10s were built by Fairchild in Hagerstown, Maryland. After trials and a fly-off against the YA-9, on 18 January 1973, the USAF announced the YA-10's selection for production. General Electric was selected to build the GAU-8 cannon in June 1973. The YA-10 had an additional fly-off in 1974 against the Ling-Temco-Vought A-7D Corsair II, the principal USAF attack aircraft at the time, to prove the need for a new attack aircraft. The first production A-10 flew in October 1975, and deliveries commenced in March 1976.
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One experimental two-seat A-10 Night Adverse Weather (N/AW) version was built by converting an A-10A. The N/AW was developed by Fairchild from the first Demonstration Testing and Evaluation (DT&E) A-10 for consideration by the USAF. It included a second seat for a weapon systems officer responsible for electronic countermeasures (ECM), navigation and target acquisition. The N/AW version did not interest the USAF or export customers. The two-seat trainer version was ordered by the Air Force in 1981, but funding was canceled by U.S. Congress and the trainer was not produced. The only two-seat A-10 resides at Edwards Air Force Base's Flight Test Center Museum.
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On 10 February 1976, Deputy Secretary of Defense Bill Clements authorized full-rate production, with the first A-10 being accepted by the Air Force Tactical Air Command on 30 March 1976. Production continued and reached a peak rate of 13 aircraft per month. By 1984, 715 airplanes, including two prototypes and six development aircraft, had been delivered.
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When A-10 full-rate production was first authorized the aircraft's planned service life was 6,000 hours. A small reinforcement to the design was quickly adopted when the A-10 failed initial fatigue testing at 80% of testing; with the fix, the A-10 passed the fatigue tests. 8,000-flight-hour service lives were becoming common at the time, so fatigue testing of the A-10 continued with a new 8,000-hour target. This new target quickly discovered serious cracks at Wing Station 23 (WS23) where the outboard portions of the wings are joined to the fuselage. The first production change was to add cold working at WS23 to address this problem. Soon after, the Air Force determined that the real-world A-10 fleet fatigue was more harsh than estimated, forcing them to change their fatigue testing and introduce "spectrum 3" equivalent flight-hour testing.
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Spectrum 3 fatigue testing started in 1979. This round of testing quickly determined that more drastic reinforcement would be needed. The second change in production, starting with aircraft No. 442, was to increase the thickness of the lower skin on the outer wing panels. A tech order was issued to retrofit the "thick skin" to the whole fleet, but the tech order was rescinded after roughly 242 planes, leaving about 200 planes with the original "thin skin". Starting with aircraft No. 530, cold working at WS0 was performed, and this retrofit was performed on earlier aircraft. A fourth, even more drastic change was initiated with aircraft No. 582, again to address the problems discovered with spectrum 3 testing. This change increased the thickness of the lower skin on the center wing panel, but it required modifications to the lower spar caps to accommodate the thicker skin. The Air Force determined that it was not economically feasible to retrofit earlier planes with this modification.
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The A-10 has received many upgrades since entering service. In 1978, the A-10 received the Pave Penny laser receiver pod, which receives reflected laser radiation from laser designators to allow the aircraft to deliver laser guided munitions. The Pave Penny pod is carried on a pylon mounted below the right side of the cockpit and has a clear view of the ground. In 1980, the A-10 began receiving an inertial navigation system.
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In the early 1990s, the A-10 began to receive the Low-Altitude Safety and Targeting Enhancement (LASTE) upgrade, which provided computerized weapon-aiming equipment, an autopilot, and a ground-collision warning system. In 1999, aircraft began receiving Global Positioning System navigation systems and a multi-function display. The LASTE system was upgraded with an Integrated Flight & Fire Control Computer (IFFCC).
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Proposed further upgrades included integrated combat search and rescue locator systems and improved early warning and anti-jam self-protection systems, and the Air Force recognized that the A-10's engine power was sub-optimal and had been planning to replace them with more powerful engines since at least 2001 at an estimated cost of $2 billion.
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In 1987, Grumman Aerospace took over support for the A-10 program. In 1993, Grumman updated the damage tolerance assessment and Force Structural Maintenance Plan and Damage Threat Assessment. Over the next few years, problems with wing structure fatigue, first noticed in production years earlier, began to come to the fore. The process of implementing the maintenance plan was greatly delayed by the base realignment and closure commission (BRAC), which led to 80% of the original workforce being let go.
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During inspections in 1995 and 1996, cracks at the WS23 location were found on many aircraft, most of them in line with updated predictions from 1993. However, two of these were classified as "near-critical" size, well beyond predictions. In August 1998, Grumman produced a new plan to address these issues and increase life span to 16,000 hours. This resulted in the "HOG UP" program, which commenced in 1999. Over time, additional aspects were added to HOG UP, including new fuel bladders, changes to the flight control system, and inspections of the engine nacelles. In 2001, the cracks were reclassified as "critical", which meant they were considered repairs and not upgrades, which allowed bypassing normal acquisition channels for more rapid implementation.
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An independent review of the HOG UP program at this point concluded that the data on which the wing upgrade relied could no longer be trusted. This independent review was presented in September 2003. Shortly thereafter, fatigue testing on a test wing failed prematurely and also mounting problems with wings failing in-service inspections at an increasing rate became apparent. The Air Force estimated that they would run out of wings by 2011. Of the plans explored, replacing the wings with new ones was the least expensive, with an initial cost of $741 million, and a total cost of $1.72 billion over the life of the program.
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In 2005, a business case was developed with three options to extend the life of the fleet. The first two options involved expanding the service life extension program (SLEP) at a cost of $4.6 billion and $3.16 billion, respectively. The third option, worth $1.72 billion, was to build 242 new wings and avoid the cost of expanding the SLEP. In 2006, option 3 was chosen and Boeing won the contract. The base contract is for 117 wings with options for 125 additional wings. In 2013, the Air Force exercised a portion of the option to add 56 wings, putting 173 wings on order with options remaining for 69 additional wings. In November 2011, two A-10s flew with the new wings fitted. The new wings improved mission readiness, decreased maintenance costs, and allowed the A-10 to be operated up to 2035 if necessary. The re-winging effort was organized under the Thick-skin Urgent Spares Kitting (TUSK) Program.
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In 2014, as part of plans to retire the A-10, the USAF considered halting the wing replacement program to save an additional $500 million; however, by May 2015 the re-winging program was too far into the contract to be financially efficient to cancel. Boeing stated in February 2016 that the A-10 fleet with the new TUSK wings could operate to 2040.
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In 2005, the entire fleet of 356 A-10 and OA-10 aircraft began receiving the Precision Engagement upgrades including an improved fire control system (FCS), electronic countermeasures (ECM), and smart bomb targeting. The aircraft receiving this upgrade were redesignated A-10C. The Government Accountability Office in 2007 estimated the cost of upgrading, refurbishing, and service life extension plans for the A-10 force to total $2.25 billion through 2013. In July 2010, the USAF issued Raytheon a contract to integrate a Helmet Mounted Integrated Targeting (HMIT) system into the A-10C. The Air Force Materiel Command's Ogden Air Logistics Center at Hill AFB, Utah completed work on its 100th A-10 precision engagement upgrade in January 2008. The final aircraft was upgraded to A-10C configuration in June 2011. The aircraft also received all-weather combat capability, and a Hand-on-Throttle-and-Stick configuration mixing the F-16's flight stick with the F-15's throttle. Other changes included two multifunction displays, a modern communications suite including a Link-16 radio and SATCOM. The LASTE system was replaced with the integrated flight and fire control computer (IFFCC) included in the PE upgrade.
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Throughout its life, the platform's software has been upgraded several times, and although these upgrades were due to be stopped as part of plans to retire the A-10 in February 2014, Secretary of the Air Force Deborah Lee James ordered that the latest upgrade, designated Suite 8, continue in response to Congressional pressure. Suite 8 software includes IFF Mode 5, which modernizes the ability to identify the A-10 to friendly units. Additionally, the Pave Penny pods and pylons are being removed as their receive-only capability has been replaced by the AN/AAQ-28(V)4 LITENING AT targeting pods or Sniper XR targeting pod, which both have laser designators and laser rangefinders.
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In 2012, Air Combat Command requested the testing of a external fuel tank which would extend the A-10's loitering time by 45–60 minutes; flight testing of such a tank had been conducted in 1997 but did not involve combat evaluation. Over 30 flight tests were conducted by the 40th Flight Test Squadron to gather data on the aircraft's handling characteristics and performance across different load configurations. It was reported that the tank slightly reduced stability in the yaw axis, but there was no decrease in aircraft tracking performance.
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The A-10 has a cantilever low-wing monoplane wing with a wide chord. The aircraft has superior maneuverability at low speeds and altitude because of its large wing area, high wing aspect ratio, and large ailerons. The wing also allows short takeoffs and landings, permitting operations from primitive forward airfields near front lines. The aircraft can loiter for extended periods and operate under ceilings with visibility. It typically flies at a relatively low speed of , which makes it a better platform for the ground-attack role than fast fighter-bombers, which often have difficulty targeting small, slow-moving targets.
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The leading edge of the wing has a honeycomb structure panel construction, providing strength with minimal weight; similar panels cover the flap shrouds, elevators, rudders and sections of the fins. The skin panels are integral with the stringers and are fabricated using computer-controlled machining, reducing production time and cost. Combat experience has shown that this type of panel is more resistant to damage. The skin is not load-bearing, so damaged skin sections can be easily replaced in the field, with makeshift materials if necessary. The ailerons are at the far ends of the wings for greater rolling moment and have two distinguishing features: The ailerons are larger than is typical, almost 50 percent of the wingspan, providing improved control even at slow speeds; the aileron is also split, making it a deceleron.
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The A-10 is designed to be refueled, rearmed, and serviced with minimal equipment. Its simple design enables maintenance at forward bases with limited facilities. An unusual feature is that many of the aircraft's parts are interchangeable between the left and right sides, including the engines, main landing gear, and vertical stabilizers. The sturdy landing gear, low-pressure tires and large, straight wings allow operation from short rough strips even with a heavy aircraft ordnance load, allowing the aircraft to operate from damaged airbases, flying from taxiways, or even straight roadway sections.
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The front landing gear is offset to the aircraft's right to allow placement of the 30 mm cannon with its firing barrel along the centerline of the aircraft. During ground taxi, the offset front landing gear causes the A-10 to have dissimilar turning radii; turning to the right on the ground takes less distance than turning left. The wheels of the main landing gear partially protrude from their nacelles when retracted, making gear-up belly landings easier to control and less damaging. All landing gears retract forward; if hydraulic power is lost, a combination of gravity and aerodynamic drag can lower and lock the gear in place.
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The A-10 is battle-hardened to an exceptional degree, being able to survive direct hits from armor-piercing and high-explosive projectiles up to 23 mm. It has double-redundant hydraulic flight systems, and a mechanical system as a backup if hydraulics are lost. Flight without hydraulic power uses the manual reversion control system; pitch and yaw control engages automatically, roll control is pilot-selected. In manual reversion mode, the A-10 is sufficiently controllable under favorable conditions to return to base, though control forces are greater than normal. The aircraft is designed to be able to fly with one engine, half of the tail, one elevator, and half of a wing missing.
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The cockpit and parts of the flight-control systems are protected by of titanium aircraft armor, referred to as a "bathtub". The armor has been tested to withstand strikes from 23 mm cannon fire and some indirect hits from 57 mm shell fragments. It is made up of titanium plates with thicknesses varying from determined by a study of likely trajectories and deflection angles. The armor makes up almost six percent of the aircraft's empty weight. Any interior surface of the tub directly exposed to the pilot is covered by a multi-layer nylon spall shield to protect against shell fragmentation. The front windscreen and canopy are resistant to small arms fire.
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The A-10's durability was demonstrated on 7 April 2003 when Captain Kim Campbell, while flying over Baghdad during the 2003 invasion of Iraq, suffered extensive flak damage. Iraqi fire damaged one of her engines and crippled the hydraulic system, requiring the aircraft's stabilizer and flight controls to be operated via the 'manual reversion mode.' Despite this damage, Campbell flew the aircraft for nearly an hour and landed safely.
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The A-10 was intended to fly from forward air bases and semi-prepared runways where foreign object damage to an aircraft's engines is normally a high risk. The unusual location of the General Electric TF34-GE-100 turbofan engines decreases ingestion risk and also allows the engines to run while the aircraft is serviced and rearmed by ground crews, reducing turn-around time. The wings are also mounted closer to the ground, simplifying servicing and rearming operations. The heavy engines require strong supports: four bolts connect the engine pylons to the airframe. The engines' high 6:1 bypass ratio contributes to a relatively small infrared signature, and their position directs exhaust over the tailplanes further shielding it from detection by infrared homing surface-to-air missiles. The engines' exhaust nozzles are angled nine degrees below horizontal to cancel out the nose-down pitching moment that would otherwise be generated from being mounted above the aircraft's center of gravity and avoid the need to trim the control surfaces to prevent pitching.
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To reduce the likelihood of damage to the A-10's fuel system, all four fuel tanks are located near the aircraft's center and are separated from the fuselage; projectiles would need to penetrate the aircraft's skin before reaching a tank's outer skin. Compromised fuel transfer lines self-seal; if damage exceeds a tank's self-sealing capabilities, check valves prevent fuel flowing into a compromised tank. Most fuel system components are inside the tanks so that fuel will not be lost due to component failure. The refueling system is also purged after use. Reticulated polyurethane foam lines both the inner and outer sides of the fuel tanks, retaining debris and restricting fuel spillage in the event of damage. The engines are shielded from the rest of the airframe by firewalls and fire extinguishing equipment. In the event of all four main tanks being lost, two self-sealing sump tanks contain fuel for 230 miles (370 km) of flight.
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Since the A-10 operates very close to enemy positions, where it is an easy target for man-portable air-defense system (MANPADS), surface-to-air missiles (SAMs), and enemy aircraft, it carries both flares and chaff cartridges.
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Although the A-10 can carry a considerable amount of munitions, its primary built-in weapon is the 30×173 mm GAU-8/A Avenger autocannon. One of the most powerful aircraft cannons ever flown, it fires large depleted uranium armor-piercing shells. The GAU-8 is a hydraulically driven seven-barrel rotary cannon designed specifically for the anti-tank role with a high rate of fire. The cannon's original design could be switched by the pilot to 2,100 or 4,200 rounds per minute; this was later changed to a fixed rate of 3,900 rounds per minute. The cannon takes about half a second to reach top speed, so 50 rounds are fired during the first second, 65 or 70 rounds per second thereafter. The gun is accurate enough to place 80 percent of its shots within a 40-foot (12.4 m) diameter circle from 4,000 feet (1,220 m) while in flight. The GAU-8 is optimized for a slant range of with the A-10 in a 30-degree dive.
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The fuselage of the aircraft is built around the cannon. The GAU-8/A is mounted slightly to the port side; the barrel in the firing location is on the starboard side so it is aligned with the aircraft's centerline. The gun's 5-foot, 11.5-inch (1.816 m) ammunition drum can hold up to 1,350 rounds of 30 mm ammunition, but generally holds 1,174 rounds. To protect the GAU-8/A rounds from enemy fire, armor plates of differing thicknesses between the aircraft skin and the drum are designed to detonate incoming shells.
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The AGM-65 Maverick air-to-surface missile is a commonly used munition for the A-10, targeted via electro-optical (TV-guided) or infrared. The Maverick allows target engagement at much greater ranges than the cannon, and thus less risk from anti-aircraft systems. During Desert Storm, in the absence of dedicated forward-looking infrared (FLIR) cameras for night vision, the Maverick's infrared camera was used for night missions as a "poor man's FLIR". Other weapons include cluster bombs and Hydra 70 rocket pods. The A-10 is equipped to carry GPS- and laser-guided bombs, such as the GBU-39 Small Diameter Bomb, Paveway series bombs, Joint Direct Attack Munitions (JDAM), Wind Corrected Munitions Dispenser and AGM-154 Joint Standoff Weapon glide bombs. A-10s usually fly with an ALQ-131 Electronic countermeasures (ECM) pod under one wing and two AIM-9 Sidewinder air-to-air missiles for self-defense under the other wing.
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The A-10 Precision Engagement Modification Program from 2006 to 2010 updated all A-10 and OA-10 aircraft in the fleet to the A-10C standard with a new flight computer, new glass cockpit displays and controls, two new color displays with moving map function, and an integrated digital stores management system.
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Since then, the A-10 Common Fleet Initiative has led to further improvements: a new wing design, a new data link, the ability to employ smart weapons such as the Joint Direct Attack Munition (JDAM) and Wind Corrected Munitions Dispenser, as well as the newer GBU-39 Small Diameter Bomb, and the ability to carry an integrated targeting pod such as the Northrop Grumman Litening or the Lockheed Martin Sniper Advanced Targeting Pod (ATP). Also included is the Remotely Operated Video Enhanced Receiver (ROVER) to provide sensor data to personnel on the ground. The A-10C has a Missile Warning System (MWS), which alerts the pilot to whenever there is a missile launch, friendly or non-friendly. The A-10C can also carry a ALQ-184 ECM Pod, which works with the MWS to detect a missile launch, figure out what kind of vehicle is launching the missile or flak (i.e.: SAM, aircraft, flak, MANPAD, etc.) and then jams it with confidential emitting, and selects a countermeasure program that the pilot has pre-set, that when turned on, will automatically dispense flare and chaff at pre-set intervals and amounts.
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Since the A-10 flies low to the ground and at subsonic speed, aircraft camouflage is important to make the aircraft more difficult to see. Many different types of paint schemes have been tried. These have included a "peanut scheme" of sand, yellow and field drab; black and white colors for winter operations and a tan, green and brown mixed pattern. Many A-10s also featured a false canopy painted in dark gray on the underside of the aircraft, just behind the gun. This form of automimicry is an attempt to confuse the enemy as to aircraft attitude and maneuver direction. Many A-10s feature nose art, such as shark mouth or warthog head features.
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The two most common markings applied to the A-10 have been the European I woodland camouflage scheme and a two-tone gray scheme. The European woodland scheme was designed to minimize visibility from above, as the threat from hostile fighter aircraft was felt to outweigh that from ground-fire. It uses dark green, medium green and dark gray to blend in with the typical European forest terrain and was used from the 1980s to the early 1990s. Following the end of the Cold War, and based on experience during the 1991 Gulf War, the air-to-air threat was no longer seen to be as important as that from ground fire, and a new color scheme known as "Compass Ghost" was chosen to minimize visibility from below. This two-tone gray scheme has darker gray color on top, with the lighter gray on the underside of the aircraft, and started to be applied from the early 1990s.
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The first unit to receive the A-10 Thunderbolt II was the 355th Tactical Training Wing, based at Davis-Monthan Air Force Base, Arizona, in March 1976. The first unit to achieve full combat readiness was the 354th Tactical Fighter Wing at Myrtle Beach Air Force Base, South Carolina, in October 1977. Deployments of A-10As followed at bases both at home and abroad, including England AFB, Louisiana; Eielson AFB, Alaska; Osan Air Base, South Korea; and RAF Bentwaters/RAF Woodbridge, England. The 81st TFW of RAF Bentwaters/RAF Woodbridge operated rotating detachments of A-10s at four bases in Germany known as Forward Operating Locations (FOLs): Leipheim, Sembach Air Base, Nörvenich Air Base, and RAF Ahlhorn.
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A-10s were initially an unwelcome addition to many in the Air Force. Most pilots switching to the A-10 did not want to because fighter pilots traditionally favored speed and appearance. In 1987, many A-10s were shifted to the forward air control (FAC) role and redesignated "OA-10". In the FAC role, the OA-10 is typically equipped with up to six pods of 2.75 inch (70 mm) Hydra rockets, usually with smoke or white phosphorus warheads used for target marking. OA-10s are physically unchanged and remain fully combat capable despite the redesignation.
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A-10s of the 23rd TFW were deployed to Bridgetown, Barbados during Operation Urgent Fury, the 1983 American Invasion of Grenada. They provided air cover for the U.S. Marine Corps landings on the island of Carriacou in late October 1983, but did not fire weapons as Marines met no resistance.
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The A-10 was used in combat for the first time during the Gulf War in 1991, with 132 being deployed. A-10s shot down two Iraqi helicopters with the GAU-8 cannon. The first of these was shot down by Captain Robert Swain over Kuwait on 6 February 1991 for the A-10's first air-to-air victory. Four A-10s were shot down during the war by surface-to-air missiles and eleven A-10s were hit by anti-air artillery rounds. Another two battle-damaged A-10s and OA-10As returned to base and were written off. Some sustained additional damage in crash landings. In the beginning of the war, A-10s flew missions against the Iraqi Republican Guard, but due to heavy attrition, from the 15 February they were restricted to within 20 nautical miles (37 km) of the southern border. A-10s also flew missions hunting Iraqi Scud missiles. The A-10 had a mission capable rate of 95.7 percent, flew 8,100 sorties, and launched 90 percent of the AGM-65 Maverick missiles fired in the conflict. Shortly after the Gulf War, the Air Force abandoned the idea of replacing the A-10 with a close air support version of the F-16.<ref name="F/A-16">"A-16 Close Air Support". "F-16.net". Retrieved 5 March 2010.</ref>
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U.S. Air Force A-10 aircraft fired approximately 10,000 30 mm rounds in Bosnia and Herzegovina in 1994–95. Following the seizure of some heavy weapons by Bosnian Serbs from a warehouse in Ilidža, a series of sorties were launched to locate and destroy the captured equipment. On 5 August 1994, two A-10s located and strafed an anti-tank vehicle. Afterward, the Serbs agreed to return the remaining heavy weapons. In August 1995, NATO launched an offensive called Operation Deliberate Force. A-10s flew close air support missions, attacking Bosnian Serb artillery and positions. In late September, A-10s began flying patrols again.
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A-10s returned to the Balkan region as part of Operation Allied Force in Kosovo beginning in March 1999. In March 1999, A-10s escorted and supported search and rescue helicopters in finding a downed F-117 pilot. The A-10s were deployed to support search and rescue missions, but over time the Warthogs began to receive more ground attack missions. The A-10's first successful attack in Operation Allied Force happened on 6 April 1999; A-10s remained in action until combat ended in late June 1999.
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During the 2001 invasion of Afghanistan, A-10s did not take part in the initial stages. For the campaign against Taliban and Al Qaeda, A-10 squadrons were deployed to Pakistan and Bagram Air Base, Afghanistan, beginning in March 2002. These A-10s participated in Operation Anaconda. Afterward, A-10s remained in-country, fighting Taliban and Al Qaeda remnants.
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Operation Iraqi Freedom began on 20 March 2003. Sixty OA-10/A-10 aircraft took part in early combat there. United States Air Forces Central Command issued "Operation Iraqi Freedom: By the Numbers", a declassified report about the aerial campaign in the conflict on 30 April 2003. During that initial invasion of Iraq, A-10s had a mission capable rate of 85 percent in the war and fired 311,597 rounds of 30 mm ammunition. A single A-10 was shot down near Baghdad International Airport by Iraqi fire late in the campaign. The A-10 also flew 32 missions in which the aircraft dropped propaganda leaflets over Iraq.
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In September 2007, the A-10C with the Precision Engagement Upgrade reached initial operating capability. The A-10C first deployed to Iraq in 2007 with the 104th Fighter Squadron of the Maryland Air National Guard. The A-10C's digital avionics and communications systems have greatly reduced the time to acquire a close air support target and attack it.
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