Total force health sys 26 jan 10

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  • Meet the Army ’s mission, manpower and quality objectives. Graduate Soldiers who can “mobilize, deploy, fight, sustain, and win any conflict” as units with Warrior Ethos and Values. Graduate Soldiers who are physically healthy, task-relevant physically fit, mentally resilient, and deployable.
  • Bombs and bullets aren't soldiers' biggest dangers WAR: Injuries and illness take more soldiers away from battlefields in Iraq and Afghanistan. BY DREW BROWN KNIGHT RIDDER NEWSPAPERS WASHINGTON - Enemy bombs are the biggest killer of U.S. troops in Iraq, but the armed forces have lost more men and women to illnesses and noncombat injuries than they have to enemy fire. Despite advances in technology, top-notch training and equipment, state-of-the-art medical care and a 2003 order by Defense Secretary Donald Rumsfeld to cut the number of preventable accidents in half, broken bones and bad health have taken more U.S. soldiers off the battlefield than combat has. By mid-December, more than 25,803 American service members had been evacuated from Iraq since the war began nearly three years ago, according to Pentagon officials. Nearly 80 percent of them were shipped out because of routine illnesses and injuries unrelated to combat. Historically, accidents have caused about half of the U.S. military's wartime injuries and deaths. But Rumsfeld's 2003 directive has had an effect, said David Chu, the undersecretary of defense for personnel. As a result, "about 26 percent of the losses (in Iraq) result from preventable mishaps," Chu told the Senate Armed Services Committee last February. Pentagon health officials said the decline was the r esult of better medical care and efforts to prevent accidents and illnesses. Still, vehicle accidents have killed more troops than insurgent mortar and rocket attacks. According to Pentagon statistics through mid-December, at least 158 American service members in Iraq have died in vehicle accidents since the war began. Mortar and rocket attacks have killed 156 U.S. service members and wounded more than 1,900. Enemy fire has wounded more than 16,000 American troops in Iraq. More than half of those returned to duty within three days. Nonbattle injuries and disease had caused the evacuations of 20,449 U.S. troops from Iraq through mid-December, Pentagon statistics show. Officials estimate that about 25 percent of those who are evacuated for injuries or illnesses eventually return to the combat zone. As dangerous and unsanitary as battlefield conditions are, better medical care and preventive medicine mean that the rates of nonbattle injuries and disease "have been lower than in any other conflict," Chu said in February.
  • 2005: Lappe Joan; Davies Kennard; Recker Robert; Heaney Robert Quantitative Ultrasound: Use In Screening For Susceptibility To Stress Fractures In Female Army Recruits. Journal Of Bone And Mineral Research, 2005;20(4):571-8. Evaluation Of A Progressive Unit-based Running Program During Advanced Individual Training, Col Valerie J. Berg Rice Et Al, Department Of Medical Science, U.S. Army Medical Department Center And School, Ft. Sam Houston, San Antonio, TX 78234-6000, November 2001 A COMBINED MACRO ERGONOMICS & PUBLIC HEALTH APPROACH TO INJURY PREVENTION: TWO YEARS LATER Valerie J. Berg Rice, Phd And Clayton Gable, Phd* Human Research And Engineering Directorate U.S. Army Research Laboratory U.S. Army Medical Department Center And School Ft. Sam Houston, San Antonio, Texas Calcium And Vitamin D Supplementation Decreases Incidence Of Stress Fractures In Female Navy Recruits Joan Lappe,1 Diane Cullen,1 Gleb Haynatzki,1 Robert Recker,1 Renee Ahlf,2 And Kerry Thompson2 JOURNAL OF BONE AND MINERAL RESEARCH Volume 23, Number 5, 2008 Published Online On February 4, 2008; Doi: 10.1359/Jbmr.080102 © 2008 American Society For Bone And Mineral Research Health, Performance, And Nutritional Status Of US Army Women During Basic Combat Training, Westphal Et Al, 1995, USARIEM, DTIC Prevalence Of Iron Deficiency And Iron Deficiency Anemia Among Three Populations Of Female Military Personnel In The US Army, Mcclung Et Al, Journal Of The American College Of Nutrition, Vol 25, No. 1, 2006. Randomized, Double-blind, Placebo-controlled Trial Of Iron Supplementation In Female Soldiers During Military Training: Effects On Iron Status, Physical Performance, And Mood1–5 James P Mcclung, Am J Clin Nutr 2009;90:1–8.
  • Only 3 out of 10 are fully qualified without waivers. That ’s BEFORE we consider propensity to join!
  • The ‘obesity epidemic’ has a dramatic effect on the recruitable population, especially diversity.
  • If fatness trends continue, this is the impact on recruiting in 2015-2020. One option is to adjust our standards, There is no validity to the current age-adjusted BF standards. Our current ARMS study shows OW folks doing very well.
  • JOURNAL OF BONE AND MINERAL RESEARCH, Volume 20, Number 4, 2005 Published online on December 6, 2004; doi: 10.1359/JBMR.041208 © 2005 American Society for Bone and Mineral Research Quantitative Ultrasound: Use in Screening for Susceptibility to Stress Fractures in Female Army Recruits, Joan Lappe, Kennard Davies, Robert Recker, and Robert Heaney FRAX Bone Treatment Algorithm: A Revised Clinician's Guide to the Prevention and Treatment of Osteoporosis- commentary     The Journal of Clinical Endocrinology & Metabolism July 2008 Vol. 93, No. 7 2463-2465 Bess Dawson-Hughes on behalf of the National Osteoporosis Foundation Guide Committee Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts 02111 INTRODUCTION Osteoporosis is an important health problem now, and the incidence of fractures and their associated costs are rising rapidly as our population ages (1). The National Osteoporosis Foundation (NOF) has estimated that by 2010, 12 million men and women in the United States will have osteoporosis and over 40 million more will have low bone mass (2). There is little controversy about whether individuals who present with osteoporosis should be considered for pharmacotherapy. Among patients with low bone mass, however, we need better discrimination of those at high risk for fracture, to maximize the benefit while limiting the risks and costs that accompany treatment. In this spirit, the NOF has collaborated with the World Health Organization (WHO) to adapt its newly developed fracture prediction algorithm (FRAX) to the U.S. population (3), performed an economic analysis to identify levels of fracture risk above which it is cost-effective to consider pharmacotherapy in this country (4), and revised the NOF Clinician's Guide for the Prevention and Treatment of Osteoporosis (www.NOF.org). This Commentary provides a brief overview of this process, a summary of the key recommendations of the Guide, and a consideration of work that remains. The U.S.-adapted FRAX algorithm is available on the NOF website (www.NOF.org) and atwww.shef.ac.uk/FRAX. The Committee also performed a cost-effectiveness analysis to estimate the levels of fracture risk above which it is reasonable to consider treatment (4). The practical implications of this analysis are described in a companion paper (3). The new NOF Clinician's Guide (available on the NOF website at www.NOF.org) indicates 10-yr fracture risk thresholds above which it is reasonable to consider pharmacological treatment. Work is now underway to evaluate the potential impact of the Guide by estimating the number of men and women who are expected to meet the new treatment criteria.
  • Corrected deficits Increased ham/quad ratio from 51% to 60% Improved ham/quad ratio 13% dominant side; 26% non-dominant side Decreased landing forces Landing force from jump: 22% Knee adduction and abduction moments: 50% Increased power, strength, jump height Ham power 44% dominant side, 21% non-dominant side Mean vertical jump:10%
  • Schools shifted to soda machines and fast food restaurants instead of cafeterias to defray costs. Teens rarely drink milk anymore, preferring sodas. Teenage women may have severely unbalanced diets which can result in anemias. You see here that 56% entered iron anemic. However, you also see the Army diet was inadequate and their status worsened. We are currently doing a study at Fort Jackson to try and correct. We can ask the same questions about MREs.
  • CALCIUM AND VITAMIN D SUPPLEMENTATION REDUCES INCIDENCE OF STRESS FRACTURES IN NAVY RECRUITS +*Lappe, J.M.; *Cullen, D.M.;**Thompson, K.; **Ahlf, R. +*Creighton University, Omaha NE jmlappe@creighton.edu NOTE: Bone as living tissue needs a variety of nutrients.
  • Available at: http://en.wikipedia.org/wiki/Abiogenesis. Accessed September 4, 2008. Faloon W. Should the president declare a national emergency? Life Extension. 2007 Oct;13(10):7-17. Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med. 2008 Jun 9;168(11):1174-80. Available at: www.americanheart.org/downloadable/heart/1200082005246HS_Stats%202008.final.pdf.Accessed October 29, 2008. Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med. 2008 Jun 23;168(12):1340-9. Holick MF. Vitamin D and sunlight: strategies for cancer prevention and other health benefits. Clin J Am Soc Nephrol. 2008 Sep;3(5):1548-54. Available at: www.cdc.gov/cancer/colorectal/statistics/. Accessed September 4, 2008. Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586-91. Brown ML, Lipscomb J, Snyder C. The burden of illness and cancer: economic cost and quality of life. Annu Rev Public Health. 2001;22:91-113. Abbas S, Linseisen J, Slanger T, et al. Serum 25-hydroxyvitamin D and risk of post-menopausal breast cancer--results of a large case-control study. Carcinogenesis. 2008 Jan;29(1):93-9. Rossi M, McLaughlin JK, Lagiou P, et al. Vitamin D intake and breast cancer risk: a case-control study in Italy. Ann Oncol. 2008 Aug 18. Giovannucci E. Vitamin D and cancer incidence in the Harvard Cohorts. Ann Epidemiol. 2008 Feb 19. Abbas S, Linseisen J, Chang-Claude J. Dietary vitamin D and calcium intake and premenopausal breast cancer risk in a German case-control study. Nutr Cancer. 2007;59(1):54-61. Robien K, Cutler GJ, Lazovich D. Vitamin D intake and breast cancer risk in postmenopausal women: the Iowa Women ’s Health Study. Cancer Causes Control. 2007 Sep;18(7):775-82. Available at: www.cdc.gov/cancer/breast/statistics/. Accessed October 28, 2008. Available at: www.cdc.gov/cancer/prostate/statistics/. Accessed October 28, 2008. Li H, Stampfer MJ, Hollis JB, et al. A prospective study of plasma vitamin D metabolites, vitamin D receptor polymorphisms, and prostate cancer. PLoS Med. 2007 Mar;4(3):e103. Wilson LS, Tesoro R, Elkin EP, et al. Cumulative cost pattern comparison of prostate cancer treatments. Cancer. 2007 Feb 1;109(3):518-27. Available at: http://vitamins-minerals.suite101.com/article.cfm/the_sunshine_vitaminhttp://www.vitamindsociety.org/. Accessed September 4, 2008. Available at: www.cdc.gov/nchs/fastats/deaths.htm. Accessed September 4, 2008. Pilz S, Dobnig H, Fischer JE, et al. Low vitamin D levels predict stroke in patients referred to coronary angiography. Stroke. 2008 Sep;39(9):2611-3. Available at: http://74.125.45.104/search?q=cache:fgZo6Q5-SO8J:www.vitamindcouncil.org/+Current+research+indicates+vitamin+D+deficiency+plays+a+role+in+causing+seventeen&hl=en&ct=clnk&cd=1&gl=us. Accessed September 4, 2008. Available at: www.nia.nih.gov/AboutNIA/NACA/MeetingInformation/DirStatusReportMay2007.htm.Accessed September 4, 2008. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr. 1999 May;69(5):842-56. Holick MF. The role of vitamin D for bone health and fracture prevention. Curr Osteoporos Rep.2006 Sep;4(3):96-102.
  • Rudzki SJ. Injuries in Australian army recruits. Part I: Decreased incidence and severity of injury seen with reduced running time. Military Medicine. 1997 162(7), 472-476. Rudzki, SJ. Injuries in Australian army recruits. Part II: Location and cause of injuries seen in recruits. Military Medicine. 1997 162(7), 477-480. Rudzki, SJ. Injuries in Australian army recruits. Part III: The accuracy of a pretraining orthopedic screen in predicting ultimate injury outcomes. Military Medicine. 1997 162(7), 481-483. Knapik, JJ, Rieger, W, Palkoska, F, Van Camp, S, and Darakjy, S. United States Army physical readiness training: rationale and evaluation of the physical training doctrine. J Strength Cond Res 23(4): 1353-1362, 2009 Epidemiologic Reviews 24:228-247 (200Johns Hopkins Bloomberg School of Public Health Prevention of Lower Extremity Stress Fractures in Athletes and Soldiers: A Systematic Review Bruce H. Jones 1 , Stephen B. Thacker 2 , Julie Gilchrist 1 , C. Dexter Kimsey, Jr. 3 and Daniel M. Sosin 2 2005: Lappe Joan; Davies Kennard; Recker Robert; Heaney Robert Quantitative ultrasound: use in screening for susceptibility to stress fractures in female army recruits. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2005;20(4):571-8. USACHPPM Report No. 21-KK-08QR-08, Recommendations for Prevention of Physical Training (PT)-Related Injuries: Results of a Systematic Evidence-Based Review by the Joint Services Physical Training Injury Prevention Work Group (JSPTIPWG) Rice, V. J., Connolly, V., and Mays, M. Z.  (2001). A comparison of traditional vs. "new" physical training:  The rest of the story.  In A.Bittner, P Champney, and S. Morrissey (Eds.)  Advances in Occupational Ergonomics and Safety, Washington, DC: IOS Press, 297-303.
  • Evaluation of the TRADOC Standardized PT Program for BCT And Evaluation of the Effectiveness of The Fitness Assessment Program, Joseph J. Knapik, Salima Darakjy, Keith Hauret, Sara Canada, Roberto Marin, Shawn Scott, William Rieger, Frank Palkoska, Steven VanCamp, Gene Piskator , US Army Center for Health Promotion and Preventive Medicine US Army Physical Fitness School US Army Training Center (Ft Jackson SC) US Army Center for Accessions Research
  • Experts learn what information is critical and what is not. The role of simple practice cannot be underestimated. We have to ask ourselves where a LT or squad leader gets 20 repetitions on ‘how to fight’ tasks ?
  • Positive leadership and training resilience are force multipliers. Soldiers regardless of their backgrounds can learn to ‘bounce back’ and overcome obstacles.
  • Total force health sys 26 jan 10

    1. 1. Conserve the Fighting Strength Total Force Plus Life-Cycle Health Readiness System One Team; One FightJim LarsenJelarsen1@cox.net
    2. 2. Issues 1. Where are the ‘human performance’ boundaries? What do we include/exclude? 2. What are the measurable outcome criteria? Combat performance or health-wellness? Operational Readiness (OR) rates? 3. CAUTION: Statistics may NOT tell us if it is: • Nosocomical • A marker • A causal agent1/26/10 2
    3. 3. Total Force Plus Life-Cycle Health Readiness System: Impacts • The Total Force Plus* health status affects: – Force mission accomplishment – Force readiness and deployability – Force manpower levels – Recruiting – Costs By 2020, 52.5% of recruitable population will be medically disqualified “Impact of Physical, Behavioral, and Moral Disqualification of Prime Market” 2005 * Total Force Plus = AC-RC Service members, recruits/cadets, spouses, children,1/26/10 and retirees/vets. 3
    4. 4. Total Force Plus Life-Cycle Health Readiness System: Why Total Force Plus? • All members affect the Total Force. • Most diseases and conditions are chronic and relatively invisible in the short-term. • “Downstream” issues highlight “upstream” issues. • Retiree Cardio Vascular Disease (CVD) may reflect years of high LDL cholesterol. • Child lead levels may reflect service member range safety issues. * Total Force Plus = AC-RC Service members, recruits/cadets, spouses, children,1/26/10 4 and retirees/vets.
    5. 5. Total Force Plus Life-Cycle Health Readiness System: Why Do We Need a Comprehensive Life Cycle System? * • Recruits enter the system with undiagnosed health issues (e.g. dental status, osteopenia, depression, alcoholism, etc.). • Recruits/Soldiers may be under-nourished, affecting performance, injury rates, attrition, and costs. • High injury rates affect deployability, manpower levels, attrition, future injury rates, and costs. • No comprehensive life cycle monitoring system means no evidence- based feedback process to build an investment strategy. “By mid-December, more than 25,803 American service members had been evacuated from Iraq since the war began nearly three years ago, according to Pentagon officials. Nearly 80 percent of them were shipped out because of routine illnesses and injuries unrelated to combat.” VA 2010 budget request is nearly $113 billion1/26/10 * See references in Notes 5
    6. 6. Less than 3 of 10 (17-24 y/o) are fully qualified to serve Less than 3 of 10 (17-24 y/o) are fully qualified to serve 36 Incarcerated 0.6 30 Numbers BEFORE Propensity is 8.8 considered Disqualified 13.9 • Medical10.7 24 • Mental • Moral 5.2 RecruitersMillions 18 6.1 must focus on finding In-Military 1.1 14 M the 7.1% 30.8 M (Prime 12 Non-HSDG 3.1 Market) HSDG < CAT IIIB 2.6 8.3 M HSDG IIIB 1.9 HSDG IIIB 1.9 6 HSDG Female I-IIIA HSDG Female I-IIIA 3.0 3.0 2.2 M HSDG Male I-IIIA 3.4 HSDG Male I-IIIA 3.4 HSDG Male I-IIIA 2.2 0 Youth Market Potential Market Qualified Market Prime Market 17-24 YO Youth Total Market minus Potential Market minus Qualified Market minus Population (M/F) - Disqualified - Cat IV - IIIB - Non-HSDG - I-IIIA Females 1/26/10 - No Waivers (1.2 M) 6 * Estimate based on 2005 Camber Prime Market Study; 2005 DOD QMA Study; 2005 Woods & Poole (2006 projections)
    7. 7. Obesity Obesity % 17-20 y/o Who Do Not Meet Army Accession Weight Standards Source: Nolte et al, “U.S. Military Weight Standards: What Percentage of U.S. Adults Meet the Current Standards?” The1/26/10 American Journal of Medicine, Vol 113, Oct 15, 2002 7
    8. 8. Obesity Obesity % 17-20 y/o Who Will Not Meet Army Accession Weight Standards in 20151/26/10 Projection based on 35% increase predicted by bariatric experts. 8
    9. 9. Osteopenia Osteopenia Source: Dr. Rivero study at Great Lakes Naval Training Center (2001-2002). • High rates of osteopenia in stress fracture cases. • Women have higher rates of osteopenia and multiple stress fractures. Note: • PT studies may have results that vary by gender.12/23/09 • Differing osteopenia rates may partially explain that. 9
    10. 10. Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army Recruits • QUS calcaneal measurements on 4,139 female Army recruits at Basic Training (BT) start. • The incidence of stress fractures were 4.7%. • The highest risk of stress fracture was found in white women in Q1 of SOS who smoked and didn’t exercise (RR, 14.4). • The combination of QUS measurements with evaluation of individual risk factors can identify recruits who are at the very highest risk of stress fracture. Note: 1.The bone strength ‘gold standard’ is Bone Geometry (USARIEM) (Peripheral quantitative computed tomography (pQCT). 2.The U.S.-adapted W.H.O. FRAX (fracture prediction) algorithm is available on the NOF website12/23/09 (www.NOF.org) and atwww.shef.ac.uk/FRAX (note criticisms of FRAX) 10
    11. 11. Total Force Plus Life-Cycle Health Readiness System: Program Structure • Monitoring systems • Training/Education • Delivery Systems • Supply Chain Control1/26/10 11
    12. 12. Total Force Plus Life-Cycle Health Readiness System: Program Structure Medical Nutrition Fitness Resilience Concept Monitoring Training/Education Delivery Supply Chain One Team; One Fight1/26/10 12
    13. 13. Total Force Plus Life-Cycle Health Readiness System: Medical Medical Nutrition Fitness Resilience Integrated Medicine* approach -Improved Stds of Care Concept -Improved Clinical Practice Guidelines -Team-based rehabilitation doctrine "The problem with sudden "The problem with sudden • Comprehensive Blood Chemistry Plus** at defined life cycle points. cardiac death is that, of all cardiac death is that, of all Monitoring • Injury/disease database (AHLTA Plus) ICW VA & Tricare the people that have heart the people that have heart disease ... half of the time disease ... half of the time • NCOES/WOES/OES (ACCP) (Spouse /family orientation) (DOD the first symptom is a the first symptom is a Training/E Schools/ local HS with mil pop) heart attack," said Dr. heart attack," said Dr. • Embedded training (posters, Jody calls, etc.) Stephen Kopecky, ducation • Diagnosis-based prescriptive (link to Ed Svcs) Stephen Kopecky, professor of medicine and professor of medicine and a cardiologist at the Mayo a cardiologist at the Mayo • Combat-model fix forward treatment (see USMC SMIP ATC) Clinic in Rochester, Minn. Clinic in Rochester, Minn. • Enhanced Specialty/MOS/ASI skills "And half of that half will "And half of that half will Delivery • Enhanced MWR staff skills and programs [die] within an hour." [die] within an hour." • Enhanced Ed Svc skills and programs • Joint programs with CDC Supply • Mixed DODMERB-MEPCOM entry screening model Chain • Recruiting/IET based ‘get ready’ programs *Health-focused medicine that treats the whole person (body, mind, and spirit), examining symptoms and causes. Ex. 1: Treating a stress fracture with casting and reduced activity and looking at bone health, nutritional deficiencies, diet, and exercise regimens. ** TBD1/26/10 13
    14. 14. Admiral Nelson 11 March 1804 to Dr. Mosely: Admiral Nelson 11 March 1804 to Dr. Mosely: “The greatest thing in all military service is health; and you will agree with me that it is easier for an “The greatest thing in all military service is health; and you will agree with me that it is easier for an officer to keep men healthy than it is for a physician to cure them”. officer to keep men healthy than it is for a physician to cure them”. • BCT (CHPPM) – Males: 19-37% are injured in a 9-wk cycle – Females: 42-67% are injured in a 9-wk cycle • Most injuries are overuse, compared to traumatic – Males: 75% – Females: 78% • Most injuries involve the lower extremity (low back, pelvis, hip and leg)* – Males: 83% – Females: 87% • Activities associated with injuries in BCT – Weight bearing activity; predominantly running, marching, walking14 1/26/10
    15. 15. Femoral Neck Fracture 1. New Clinical Practice Guideline for Hip Pain. 2. Early effective management works: a. Finding early avoids the fracture. b. 75% Increase in FNF detection Source: CPT Short, MAH, FJ ATC 1. Small numbers, but high costs. 2. No visibility at DA level. 3. 100% Medical Board.1/26/1015 4. Lifetime of treatment.
    16. 16. Fix Forward: USMC SMIP Athletic Trainer Initiative • Treat Marines forward as Warrior Athletes. • Sports Medicine Physicians. • Certified Athletic Trainers (ATC’s) – Contracted civilians who work for USMC commands. – GREEN ASSETS (NCAA model) – Aligned with SMART rehab clinic operations – Clinically supervised by Navy Sports Medicine MDs when dealing with injuries – Emphasis on prevention, education, and treatment – Collect/enter injury data into TIMS (injury database) RESULTS + Increased Paris Island grad rate (female 68.3% to • 3 trainers for Parris Island (GIT)/1 ATC for San Diego. 74.7%) • 3 Athletic Training Room (ATRs) for Parris Island + Increase in BCT Return to Full Duty (RTFD) rates from rehab: + male 55.5% to 64.3% + female 37.5% to 52.2% + Increase in BCT recycle grad rates (female 63.5% to 75%). – Decrease in BCT rehab discharge rates (male 13%; female 24%) – Decreased musculo-skeletal discharges at Infantry School (see chart at left). – Decreased attrition at OCS − male 8.7% to 3.8% − female 18.1% to 5.9%) + Greater cadre knowledge + Critical feedback on sources of injuries leading to fixes. + Conservative estimate of $3.5M in cost avoidance and $2.9M in Return on Investment in FY04 vs.. FY03.1/26/10 16
    17. 17. Prehabilitation Pre-training Post-training 1. Females are at risk for knee injuries 2. Balancing quad-ham muscles reduces knee injuries by 80%. *p< .05Injury Incidence/ 1,000 Player Exposures Untrained Trained Males Females Females Results: All Sports; All Knee Injuries per 1,000 Athlete Exposures SportsmetricsTM: the Key to Prevention of Serious Knee Ligament Injuries in Female Athletes, Catherine Walsh, M.S., Women’s Program1/26/10 Manager Cincinnati Sportsmedicine Research and Education Foundation 17
    18. 18. Total Force Plus Life-Cycle Health Readiness System: M edical Medical What Might It Look Like?1/26/10 18
    19. 19. Total Force Plus Life-Cycle Health Readiness System: Nutrition Med Nutrition Fitnes Resilienc ica l s e Evidence-based nutrition/supplementation focused on military Concept environment, gender, and tissue monitoring. Comprehensive Blood Chemistry Plus* and relevant test sampling* Monitoring • NCOES/WOES/OES (ACCP) (Spouse /family orientation) (DOD Schools/ local HS with mil pop) Training/E • Embedded training (posters, Jody calls, etc.) ducation • Diagnosis-based prescriptive (link to Ed Svcs) • Cooking classes in AAFES/Commissary/MWR • Evidence-based menu/recipes optimized for military environment • Timely access to meals within training OPTEMPO • Meal/snack frequency based on tissue needs Delivery • Warrior Bar, Warrior Pak, Warrior Drink R&D concepts • AAFES, MWR, and Commissary participation • Enhanced food/supplement inspection and sanitation counter-measures Supply • Healthy food standards (e.g. salad-bar plus beef) • Food production guidelines and inspections (management-intensive Chain grazing)1/26/10 * TBD 19
    20. 20. Army BCT Female Nutrition • Body iron stores were low pre-BCT (56%) and decreased further by graduation (84%) • Iron Anemia was correlated with poor PT performance • B vitamin levels were low normal pre-BCT and “decreased significantly over BCT.” • Menu was adequate in energy, but inadequate in B6, folic acid, calcium, magnesium, iron, and zinc. • Started Soldier Fueling Program. Source: “Health, Performance, and Nutritional Status of U.S. Army Women during Basic Combat Training,” (1995) (ADA302042)1/26/10 NOTE: Study BCT menu governed by the 1985 AR 40-25 20
    21. 21. Naval Female Recruits Calcium and Vitamin D Study Naval Female Recruits Calcium and Vitamin D Study • Stress fractures occur in 0.2-5.2 % of male recruits and 1.6-21.0% of female recruits. • Calcium Balance is compromised − Ca deficient diet upon entry in BT. Minimum recommended Ca 1,000mg/d Average Ca intake 19 – 30 yrs 600-700mg/d Median Ca intake of women during BT 700-900mg/d − High Ca losses occur in sweat during strenuous activity. Study with collegiate basketball players Klesges, et al. 1996. • Sample size: − Enrolled 4,647 − Discharged from Navy 355 − Withdrew from study 1,001 − Completed 2,803 • Treatment: − Randomized, Double Blind, Placebo Controlled − 2,000 mg Calcium & 800 IU Vit D • Results: Supplemented group had a 20% lower incidence of stress fractures than the control group. Naval Institute for Dental and Biomedical Research 211/26/10
    22. 22. Vitamin D Deficiency/Insufficiency • Military population levels unknown (small USCG study = 60% <30 ng/ml). • Endpoint decision drives numbers (variation by race and latitude). • Militarily significant outcomes (AF Flu Outbreak cost $7M).1/26/10 22
    23. 23. Anti-Inflammatory Diet
    24. 24. Total Force Plus Life-Cycle Health Readiness System: Fitness Medica Nutritio Fitness Resilienc l n e Functional/skill and team-based fitness within a quarterly periodization Concept cycle. • Annual with local quarterly periods. Monitoring • Web-based PT & periodization designer & record system. • Comprehensive injury prevention program (see Notes). • Fitness ASI. Training/E • Expanded Fitness School (includes injury prevention and rehab, nutrition, resilience, etc.). ducation • Enhanced MWR staff skills. • Spouse /family orientation.24 • Unit-based. Multiple program choices. Combat parcourse. Prehabilitation exercises. • MWR programs ICW PT school & medical (safe lifting posters; muscle balance guidelines, etc.). Delivery • National gym contract for geographically separate Ss (e.g. USCG). • DOD Schools/ local HS with mil pop. • Portable gym equipment (e.g. Exergenie) and/or gyms (see CONEX- based Army BU slide ) (ICW AAFES/MWR). • Incentivize Troops-To-Teachers to support HS PT. Supply • Army ‘theme’ (e.g. America Strong) (e.g. USMC Toys for Tots). Chain • Expand JROTC.1/26/10 24
    25. 25. Pre-BCT Training Programs are Effective 1. BLUF: The FTU PCU lowers overall discharge attrition by 500-800+ Soldiers (0.4-0.8+%), as well as lowers course attrition and injury rates. 2. 4%-7% of men and 10%-24% of women fail the RECBN 1-1-1 assessment historically. 50-75% of the PCU at GIT sites will be female. 3. PCU Results: a. Lower course attrition: In the “1-1-1 Fail No PCU” group, men are 2.5 times and women are 1.5 times more likely to attrit from BCT. b. Lower discharge attrition: In the “1-1-1 Fail No PCU” group, men are 3.0 times and women are 1.9 times more likely to be discharged from BCT. c. Lower injury rates. d. The USMA experimental PCU-X vice the traditional PCU improved female outcomes, but male outcomes were worse (but still better than no PCU). Recommendation is that USAPFS design a new PCU PT POI. e. Option: a 12 week BCT PCU company to maximize program flexibility, maintain bonding, provide non-PT training, get resourced, etc.1/26/10 25
    26. 26. USAPFS Standardized PT Program Injury Rates Good PT design maintains/exceeds standards Control Group and lowers injury rates 33% decrease Standardized PT Program Injury Control Week 1 Week 3 Week 5 Week 9 Time (in weeks)1/26/10 26
    27. 27. AM EDDC&S Operation Aegis Injury Control • BCT grads arrived at AIT with high injury rates (approx. 28% men; 48% women). • PT running was the primary cause of musculoskeletal injuries. • Changing the running program – Reduced Clinic Visits - 36.5% – Reduced Profiles - 48.6% – No difference in APFT Scores – Reduced APFT retakes - 50% – Saved 612 limited duty days/week/BN If implemented at all IET/AIT sites: $9M/yr & 1.5M limited duty days/yr Potential Savings1/26/10 27
    28. 28. Defence Injury Prevention Program (DIPP) Defence Injury Prevention Program (DIPP) Australian Department Of Defence Australian Department Of Defence 100% 100% 80%Results for Army Basic Training: Injury 80% Results for Army Basic Training: Attrition Uninjured 60% 60% Training Successes 40% 40% 1,834 Injuries 20% Prevented 20% 1,260 Discharges Prevented Injured Discharged 0% 0% 1994 1995 1996 1997 1998 1999 1994 1995 1996 1997 1998 1999 1. Reducing injuries reduced attrition: 70% reduction over 4 years in rates of injury and attrition 2. Gives CDRs the tools; harnesses Commander’s knowledge and skills working together to address their own injury problems. 3. 95% reduction in pelvic stress fracture rates in female recruits.1/26/10 28
    29. 29. Total Force Plus Life-Cycle Health Readiness System: Resilience Medica Nutrition Fitnes Resilience l s • Positive life skills to adapt to stress and hardships. Concept • Integrated resilience, Battlemind, and CONOPS sequential and progressive by level. Diagnostic test battery based training (e.g. Success Profiler) Monitoring (individual as appropriate). Training/E • Enhanced Beh Science Specialist MOS training ducation • Pre-enlistment R&D (train in/screen out) • Pre-BCT ‘get ready’ training • Chaplain combat-style resilience training in IET Delivery • Embedded training (posters, Jody calls, etc.) • NCOES/WOES/OES • Spouse /family orientation • Incentivize Troops-To-Teachers to support HS Wellness program. Supply • Army ‘theme’ (e.g. America Strong) (e.g. USMC Toys for Chain Tots) • Expand JROTC.1/26/10 29
    30. 30. Civilian Population • • Our current cohorts of DoD recruits arrive at IET with significant Our current cohorts of DoD recruits arrive at IET with significant developmental experiences: developmental experiences: – 40% come from ‘non-traditional’ homes without two consistent – 40% come from ‘non-traditional’ homes without two consistent parenting figures* parenting figures* – 19% of HS students had seriously considered attempting suicide – 19% of HS students had seriously considered attempting suicide during a 12 month period** during a 12 month period** – 8% of HS students reported making a suicide attempt in the – 8% of HS students reported making a suicide attempt in the preceding 12 month period** preceding 12 month period** Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research1/26/10 30
    31. 31. Adverse Childhood Experiences (ACE) Table shows only 2 factors. Having 3+ factors does increase risk somewhat, but does not automatically mean all are ruined. 1. More ACE factors increase risk. 2. Associated high-risk behaviors (sex, USMC National Sample Samples drugs, smoking,, etc.) 3. Associated impacts (health, disease, poor Men Women Men Women job performance, depression, etc.). Child 4. Diminished brain development. 26.7 38.3 3.2 4.8 physical 5. Treatable. Child 14.7 51.0* 3-16 12-27 sexual *Wolfe, J. (1996-2000). Adaptation to First-Term Enlistment Among Women in the Marine Corps. DAMD 17-95-1-5047.1/26/10 31
    32. 32. Adverse Childhood Experiences (ACEs) are Common in Civilian and Military Populations Exposures Civilian Army Infantry Alcohol abuse 23.5% 33.0% Mental illness 17.5% 21.1% Battered mother 11.9% 6.8% Childhood Abuse Civilian Army Infantry Psychological 10.0% 20.0% Physical 4.9% 13.8% Sexual 19.3% 3.8% •Data from civilian population from CDC ACE study (n=9,508). Infantry population based on AC combat unit (n=4,602)(WRAIR OIF /OEF behavioral health research project). Note: Data does not adjust for differences in population demographics. Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, Walter Reed Army1/26/10 Institute of Research 32
    33. 33. Attitudes The Dark Side 1. G1 Insist-Assist Study showed leaders’ attitudes affected attrition rates. a. “High Attrition Leaders” believe they were ‘gate guarders.’ b. “Low Attrition Leaders” believed they were developing Soldiers. 2. Emotional Events (‘high fear events,’ ‘food deprivation’, ‘sleep deprivation,’ ‘extreme PT,’ etc.) may be mis-perceived by some as preparing Soldiers for war, or strengthening them to cope with stress.1/26/10 33
    34. 34. Adaptive Thinking Expert Patterns of Battlefield Thinking TLAC training (with classroom  Keep a focus on mission instructor) but no OIF/OEF experience accomplishment and higher commanders intent.  Model a thinking enemy.  Consider effects of terrain.  Use all elements/systems no TLAC training and available. OIF/OEF experience  Include considerations of timing.  Exhibit visualizations that are dynamic and proactive.  Consider contingencies and no TLAC training and no remain flexible. OIF/OEF experience  Consider how your fight fits into the bigger picture from friendly and enemy perspectives. Source: ARI1/26/10 Training critical thinking works! 34
    35. 35. Positive Leadership Attention Control Cognitive Goal Peak Visualizatio Foundation s Setting n = Performance Stress & Energy Warrior Mgmt Mindset Self Regulating Instinctive Build confidence Adaptive Control attention Emotional Agile Recover energy USMA Peak Performance Mental Effort Mental ‘See’ the battlefield Model: Self critical Tactical Combat PT Training the Warrior Analytical Technical 8-Step AAR Judgmental Pentathlete Physical effort Physical Rote Repetition ARI – Infantry Forces Research Unit United States Olympic Committee 1998 The most critical training that prepared Soldiers for Human performance at elite levels is heavily dependent efficient and effective task accomplishment under life- upon intangible, mental factors, i.e. threatening, fast-paced, and stressful conditions are: • Confidence despite setbacks, • Time management • Concentration amidst distractions, • Command of the basics • Composure during times of stress. • skill mastery • Combat focus • Visualization • Repetition, and • Use of job aids1/26/10 35
    36. 36. Total Force Plus Life-Cycle Health Readiness System: Outcomes • Force mission accomplished • Force ready and deployable • Force manpower levels met • Costs equal or lower1/26/10 One Team; One Fight 36

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