2 year follow-up to original study

1. A MacroergonomicA Macroergonomic
approach to Injury Preventionapproach to Injury Prevention
Two Years Later…Two Years Later…
Valerie Rice, PhD, CPE, OTR/LValerie Rice, PhD, CPE, OTR/L
Clayton D. Gable, PhDClayton D. Gable, PhD

2. D
RA
FT
Janurary 2004
OutlineOutline
• Operation AegisOperation Aegis
• Who we wereWho we were
• What we didWhat we did
• The resultsThe results
• 232232ndnd
in 2003in 2003
• EOC Report DataEOC Report Data
• What is being done nowWhat is being done now
• PT & Injury PreventionPT & Injury Prevention

3. Operation Aegis:Operation Aegis:
Injury Control duringInjury Control during
Advanced Individual TrainingAdvanced Individual Training
COL Valerie J. Berg RiceCOL Valerie J. Berg Rice
LTC Annette BergeronLTC Annette Bergeron
MAJ Vicki ConnollyMAJ Vicki Connolly
CPT Allyson PritchardCPT Allyson Pritchard
Dr. Mary Z. MaysDr. Mary Z. Mays
SSG Mark KenyonSSG Mark Kenyon
SSG Shelia MickelsonSSG Shelia Mickelson
Ileana KingIleana King
Darrel GerikDarrel Gerik
Claude LeeClaude Lee
OPE
R A T I O N A
EGIS
INJU
R
Y
C O N T R O L P R O
G
RAM
TMC Visits: 56% for MSITMC Visits: 56% for MSI

4. BrigadeBrigade
• COL Larry E. CampbellCOL Larry E. Campbell
• COL Kenneth R. CrookCOL Kenneth R. Crook
• LTC Rosaline CardinelliLTC Rosaline Cardinelli
• LTC Brian AllgoodLTC Brian Allgood
• CPT Marc BustamanteCPT Marc Bustamante
• CPT Clyde L. HillCPT Clyde L. Hill
• CPT Greer M. Evans-CPT Greer M. Evans-
ChristopherChristopher
MedicalMedical
• COL Gemryl SammuelsCOL Gemryl Sammuels
• LTC Suzanne E. CudaLTC Suzanne E. Cuda
• LTC Stanley H. UnserLTC Stanley H. Unser
• CPT Deanna S. PekarekCPT Deanna S. Pekarek
All company commanders, all drill sergeants, cadre,All company commanders, all drill sergeants, cadre,
All TMC providers, OT/PT, Community Health NursingAll TMC providers, OT/PT, Community Health Nursing

5. D
RA
FT
Janurary 2004
Macroergonomic andMacroergonomic and
Public Health ApproachesPublic Health Approaches
ErgonomicsErgonomics
 AssessAssess
 DesignDesign
(intervention)(intervention)
 Test & evaluationTest & evaluation
Public HealthPublic Health
 SurveillanceSurveillance
 InterventionIntervention
 EvaluationEvaluation
 DisseminationDissemination

6. D
RA
FT
Janurary 2004
MacroergonomicsMacroergonomics
 Each system and each level within aEach system and each level within a
systemsystem
 Broad to FocusedBroad to Focused
 Organizational structure, resources, agencies,Organizational structure, resources, agencies,
personnel, policies, procedures, surveillancepersonnel, policies, procedures, surveillance
systems, datasystems, data
 Communication/AdvisorsCommunication/Advisors
Who will be of assistance?Who will be of assistance?
For or against?For or against?
Participatory: They shouldParticipatory: They should “own it”“own it”

7. D
RA
FT
Janurary 2004
PremisesPremises
 Top Level Support is EssentialTop Level Support is Essential
 Participatory Ergonomics/OrganizationalParticipatory Ergonomics/Organizational
EffectivenessEffectiveness
 Dictated changes, unless they are Army-wide,Dictated changes, unless they are Army-wide,
do not last - attitude/belief changes do lastdo not last - attitude/belief changes do last
 Locally dictated changes are often sabotagedLocally dictated changes are often sabotaged
 Top down, bottom up, sidewaysTop down, bottom up, sideways
 Everyone is involved & has responsibilitiesEveryone is involved & has responsibilities

8. D
RA
FT
Janurary 2004
PremisesPremises
Injury Management is aInjury Management is a
CommanderCommander’s’s ResponsibilityResponsibility
Health Care Professionals areHealth Care Professionals are
• SMESME’s’s
• AdvisorsAdvisors
• ConsultantsConsultants

9. D
RA
FT
Janurary 2004
Setting the StageSetting the Stage
(& Assessing)(& Assessing)
Understanding the LiteratureUnderstanding the Literature
Understanding the PeopleUnderstanding the People
Understanding the Rules and theUnderstanding the Rules and the
RolesRoles

10. D
RA
FT
Janurary 2004
TimelineTimeline
1999 2000 2001 2002 2003
PresidentialMemoto
Secretaryof
LaborconcerningInjuryprevention.
2Jul1999
2004
AssessmentofProblem
Via
epidemiologicalsurveillance.

11. D
RA
FT
Janurary 2004
Broad to FocusedBroad to Focused
 InformalInformal “Advisors” nationwide“Advisors” nationwide
 CDC, Universities, Ergo/Injury PreventionCDC, Universities, Ergo/Injury Prevention
Programs, Professional SocietiesPrograms, Professional Societies
 DoDDoD
 IOIPC (Ill & Occ Injury Prev Comm)IOIPC (Ill & Occ Injury Prev Comm)
 Ergonomics Committee, MWRErgonomics Committee, MWR
 Navy/Marines/AF/Corps of Engineers, CGNavy/Marines/AF/Corps of Engineers, CG
 ArmyArmy
 CHPPM, MRMC esp. USARIEM, Safety Center,CHPPM, MRMC esp. USARIEM, Safety Center,
Corps Activities/Committees, other postsCorps Activities/Committees, other posts

12. D
RA
FT
Janurary 2004
Broad to FocusedBroad to Focused
 PostPost
 MWR, Comm Health Nursing, OccupationalMWR, Comm Health Nursing, Occupational
Health, PTRP, Sports-intramural, WellnessHealth, PTRP, Sports-intramural, Wellness
Center, OH&S, Ergo CommitteeCenter, OH&S, Ergo Committee
 US Army Medical Center and SchoolUS Army Medical Center and School
 Center BrigadeCenter Brigade
 BattalionsBattalions
 CompaniesCompanies
Organizational structure, resources,
agencies, personnel,
policies, procedures,
surveillance systems, data

13. D
RA
FT
Janurary 2004
Messages toMessages to
CommandCommand
• We think we can reduce injuries.We think we can reduce injuries.
• We are here to try it.We are here to try it.
• We will use a scientific approach to discoverWe will use a scientific approach to discover
why injuries occur and how to decrease them.why injuries occur and how to decrease them.
• WeWe’ll do all we can to interfere as little as’ll do all we can to interfere as little as
possible.possible.
• We are here as allies, not adversaries.We are here as allies, not adversaries.
What are you, the PT Police???

14. Establish CommunicationEstablish Communication
PatternsPatterns
 Regular meetings at all levelsRegular meetings at all levels
 Matching rank w/ rank, mixing too!Matching rank w/ rank, mixing too!
 Matching civilians w/ rank and/or groupsMatching civilians w/ rank and/or groups
 BriefingsBriefings
 a lot or a little?a lot or a little?
 iterativeiterative
 topicstopics
 Consultants not dictators!Consultants not dictators!
0
1
2
3
4
Months 1-6 Months 7-12 Months 13 -18
Coordinating Meetings/Week

15. D
RA
FT
Janurary 2004
StaffStaff’s Perceptions’s Perceptions
• Only by knowing what theyOnly by knowing what they
think/believe, do you know how tothink/believe, do you know how to
approach and work with them...approach and work with them...
– Drill SergeantsDrill Sergeants
– CadreCadre
– CommandersCommanders

16. D
RA
FT
Janurary 2004
Can injuries be decreased byCan injuries be decreased by
changing the way you train?changing the way you train?
0 20 40 60 80
Yes
No
Don't Know
Responders
There’s nothing I can do.
It’s not my fault.
It’s BCT.

17. D
RA
FT
Janurary 2004
All this and we havenAll this and we haven’t even’t even
started our program yet?started our program yet?
 RememberRemember
• for this program there was nofor this program there was no “solution” yet“solution” yet
• tell them the solution fortell them the solution for “their problem” right away“their problem” right away
and they have to feel defensiveand they have to feel defensive
• itit’s perceived as extra work for them’s perceived as extra work for them
• they donthey don’t see the value, esp. for them’t see the value, esp. for them
• they arenthey aren’t convinced!’t convinced!
• they donthey don’t know how to “use you”’t know how to “use you”

18. D
RA
FT
Janurary 2004
At each level:At each level:
What Exists? Who is doing what,What Exists? Who is doing what,
when, and how? How does whatwhen, and how? How does what
they do relate?they do relate?
WhatWhat shouldshould be happening?be happening?
What are their attitudes/opinions?What are their attitudes/opinions?
How can we make what shouldHow can we make what should
happen, happen effectively?happen, happen effectively?

19. D
RA
FT
Janurary 2004
Initial InterventionsInitial Interventions
• Command ClimateCommand Climate
– Injury preventionInjury prevention
– PerformancePerformance
• Injury Control Advisory CommitteeInjury Control Advisory Committee
• BN Standard Operating ProceduresBN Standard Operating Procedures
• Education on Latest InformationEducation on Latest Information
• Reporting & Accountability SystemReporting & Accountability System

20. D
RA
FT
Janurary 2004
TimelineTimeline
1999 2000 2001 2002 2003
PresidentialMemoto
Secretaryof
LaborconcerningInjuryprevention.
2Jul1999
2004
AssessmentofProblem
Via
epidemiologicalsurveillance.
GeneralInjury
prevention
interventions

21. ResultsResults
General InterventionsGeneral Interventions
10.8% reduction in10.8% reduction in
clinic visitsclinic visits
720 fewer clinic visits720 fewer clinic visits
$53,560 annual savings$53,560 annual savings

22. ResultsResults
80% of injuries were strain/sprain
60% decrease
570 visits/yr/2BNs
$63,072/2BNs
0
2
4
6
8
10
Awareness
Policies
Procedures
NumberofClinicVisits
forMusculoskeletalInjuries
per100SoldiersinTraining

23. D
RA
FT
Janurary 2004
Ft. Sam Houston AITFt. Sam Houston AIT
 70% injuries due to lower70% injuries due to lower
extremity sprain, strain, painextremity sprain, strain, pain
 Two of 5 for knee and lower legTwo of 5 for knee and lower leg
 Top Causes:Top Causes:
Running - 37%Running - 37%
Marching - 13%Marching - 13%
Calisthenics - 5%Calisthenics - 5%

24. D
RA
FT
Janurary 2004
Targeted InterventionTargeted Intervention
 Half of the MSIs originated at FSHHalf of the MSIs originated at FSH
 Clinic visits and profiles primarily for LEClinic visits and profiles primarily for LE
MSI and overuse injuriesMSI and overuse injuries
 Top cause appeared to be running portionTop cause appeared to be running portion
of unit directed trainingof unit directed training

25. D
RA
FT
Janurary 2004
TimelineTimeline
1999 2000 2001 2002 2003
PresidentialMemoto
Secretaryof
LaborconcerningInjuryprevention.
2Jul1999
2004
AssessmentofProblem
Via
epidemiologicalsurveillance.
GeneralInjury
prevention
interventions
Targetedinterventions

26. D
RA
FT
Janurary 2004
Rate of New ProfilesRate of New Profiles
(EOC Report)(EOC Report)
Pre-RTPre-RT
GroupGroup
(n = 175)(n = 175)
RTRT
GroupGroup
(n = 344)(n = 344)
ChangeChange %%
ReductionReduction
ChiChi
SquareSquare
Men 29% 11% -18% -62% p < 0.01
Women 54% 45% - 9% -17% p > 0.05
Total 43% 26% -17% -40% p < 0.01

27. D
RA
FT
Janurary 2004
Surveillance TMC DataSurveillance TMC Data
New Profile RateNew Profile Rate
Pre-RTPre-RT RTRT
3.9/100 2.0/1003.9/100 2.0/100
70 visits/wk 36 visits/wk70 visits/wk 36 visits/wk
Rate of Profiles Reduced by 48.6%Rate of Profiles Reduced by 48.6%
Savings of 612 limited duty days/weekSavings of 612 limited duty days/week

28. EOC and TMC DataEOC and TMC Data
Held overHeld over pre-RTpre-RT RTRT
RAPFT FailureRAPFT Failure 6%6% 5%5%
MedicalMedical 2%2% 3%3%
WaiverWaiver 13%13% 7%7%
Clinic Visit RateClinic Visit Rate 3.5/100 2.2/1003.5/100 2.2/100
63 visits/wk 40 visits/wk63 visits/wk 40 visits/wk
Rate of Clinic Visits Reduced by 36.5%Rate of Clinic Visits Reduced by 36.5%
Cost Savings of $1679/wkCost Savings of $1679/wk

29. D
RA
FT
Janurary 2004
Estimated SavingsEstimated Savings
• $67,000/yr per BN$67,000/yr per BN
• $137,000/yr for 2 BNs at$137,000/yr for 2 BNs at
FSHFSH
• 24,490 limited duty24,490 limited duty
days/yr per BN,days/yr per BN,
• ~50,000 for 2 BNs at FSH~50,000 for 2 BNs at FSH

30. D
RA
FT
Janurary 2004
TimelineTimeline
1999 2000 2001 2002 2003
PresidentialMemoto
Secretaryof
LaborconcerningInjuryprevention.
2Jul1999
2004
AssessmentofProblem
Via
epidemiologicalsurveillance.
GeneralInjury
prevention
interventions
Targetedinterventions
232
ndBncontinued
Modifiedrunning
program

31. D
RA
FT
Janurary 2004
Training Cycles for 232Training Cycles for 232ndnd
BattalionBattalion
20022002 20032003 200200
44
CompanyCompany SepSep OctOct NovNov DecDec JanJan FebFeb MarMar AprApr MayMay JunJun JulJul AugAug SepSep OctOct NovNovDecDec JanJan
EchoEcho
FoxtrotFoxtrot 01-0301-03
AlphaAlpha 02-0302-03
BravoBravo 03-0303-03
CharlieCharlie 04-0304-03
DeltaDelta 05-0305-03
EchoEcho 06-0306-03
FoxtrotFoxtrot 07-0307-03
AlphaAlpha 08-0308-03
BravoBravo 09-0309-03
CharlieCharlie 10-0310-03
DeltaDelta 11-0311-03
EchoEcho 12-0312-03
FoxtrotFoxtrot 13-0313-03
AlphaAlpha 14-0314-03
BravoBravo 15-0315-03
CharlieCharlie 16-0316-03
DeltaDelta 17-0317-03

32. 232nd Battalion: Females
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Week of Cycle
PercentagewithNewProfiles
A-08-03
B-03-03
B-09-03
C-10-03
D-05-03
D-11-03
E-06-03
Co-Cycle-Yr
Pre
Running
Template
Intervention

33. 232nd Battalion: Males
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Week of AIT
PercentageofNewProfiles
A-08-03
B-03-03
B-09-03
C-10-03
D-05-03
D-11-03
E-06-03
Co - Cycle - Yr
Pre
Running
Template
Intervention

34. Summarized DataSummarized Data
Averages across Companies
Males
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%1
3
5
7
9
11
13
15
Week
PercentonNewProfile
Males
Pre-RT Males
RT-Males
(FY 03)

35. Summarized DataSummarized Data
Averages across Companies
Females
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Week
PercentofNewProfiles
Females
Pre-RT Females
RT-Females
(FY 03)

36. Summarized DataSummarized Data
Average Across Weeks
0%
2%
4%
6%
8%
10%
Pre-RT
Males
RT-Males 232nd
Males
Pre-RT
Females
RT-
Females
232nd
Females
Group
PercentofNewProfiles

37. D
RA
FT
Janurary 2004
RecordRecord
APFTAPFT Profile RatesProfile Rates
0
10
20
30
40
50
%of
soldiers
RAPFT
Pre-RT
RT
2003

38. What are they doing now?What are they doing now?
Operation AegisOperation Aegis 232232ndnd
‘03‘03
Injury Prevention/PT SOPInjury Prevention/PT SOP 
Injury Control Advisory CommitteeInjury Control Advisory Committee 
Running Template – StandardizedRunning Template – Standardized 
Periodic Review of Physical TrainingPeriodic Review of Physical Training
Periodic Anonymous Review of PTPeriodic Anonymous Review of PT


Attitude Surveys/QuestionsAttitude Surveys/Questions 
Risk Management Assessment (no - CTT)Risk Management Assessment (no - CTT) **

39. Operation AegisOperation Aegis 232232ndnd
‘03‘03
Identify Arriving Soldiers at RiskIdentify Arriving Soldiers at Risk
- On Profile?- On Profile?
- Pain, soreness, tenderness, swelling, stiffness in joint- Pain, soreness, tenderness, swelling, stiffness in joint
or bone?or bone?
- Injury to muscle, joint or bone in last 90 days- Injury to muscle, joint or bone in last 90 days
- Rate stress level- Rate stress level
- Rate physical fitness level- Rate physical fitness level
- Taken prescription medicine in last 30 days- Taken prescription medicine in last 30 days
- Taken over-the-counter medication in last 30 days- Taken over-the-counter medication in last 30 days








DAPFT 10 Days After ArrivalDAPFT 10 Days After Arrival
3 DAPFT & 1 FAPFT3 DAPFT & 1 FAPFT

**
EducationEducation
Drill Instructor Recertification: Injury PreventionDrill Instructor Recertification: Injury Prevention
Shoe Fit/New Shoes Regular & other as neededShoe Fit/New Shoes Regular & other as needed
Arriving Cadre/DI, Review 21-20 (PROVRBS)Arriving Cadre/DI, Review 21-20 (PROVRBS)




40. Operation AegisOperation Aegis 232232ndnd
‘03‘03
Responsibility/AccountibilityResponsibility/Accountibility
BaselineBaseline
Brigade Balanced Score Card 3-4%Brigade Balanced Score Card 3-4%
End of Cycle Review & Cmdr RptsEnd of Cycle Review & Cmdr Rpts
New and Existing ProfilesNew and Existing Profiles
(Match & Explain)(Match & Explain)
APFT Pass Rates, Scores, ProfilesAPFT Pass Rates, Scores, Profiles
APFT RetakesAPFT Retakes
Holdovers, WaiversHoldovers, Waivers
Considered in NCO/Officer EvaluationConsidered in NCO/Officer Evaluation

**







Sound BytesSound Bytes 
Best NCOs w/ D Group & Special PopsBest NCOs w/ D Group & Special Pops 

41. Pre-RTPre-RT RTRT
Initial Running DistanceInitial Running Distance 2.7 miles2.7 miles
(2.3-3.5)(2.3-3.5)
1.5 building to1.5 building to
2.7**2.7**
Running TimeRunning Time 20 min, build to20 min, build to
30**30**
Determined byDetermined by
distance anddistance and
speedspeed
SpeedSpeed Determined byDetermined by
NCO that dayNCO that day
Determined byDetermined by
ability groupability group
diagnosticdiagnostic
scores**scores**
Distance runs marking significantDistance runs marking significant
training eventstraining events
3 - 4 miles3 - 4 miles None,None, ChangeChange
of Commandof Command
Distance Runs/Week:Distance Runs/Week: 33 2-32-3
(fast, slow)(fast, slow)

42. Pre-RTPre-RT RTRT
Interval training sessions/wkInterval training sessions/wk Differed byDiffered by
companycompany
1/wk, begin wk 41/wk, begin wk 4
Hill run or speed trainingHill run or speed training 1/wk1/wk See intervalSee interval
training, no hilltraining, no hill
runs per seruns per se
Runs/wkRuns/wk 3-43-4 33
Ability GroupsAbility Groups 4 – 6 (typical 6,4 – 6 (typical 6,
depended ondepended on
availableavailable
supervision)supervision)
Up to 7, spreadUp to 7, spread
times no moretimes no more
than 1.5-2 minthan 1.5-2 min
4 groups4 groups
Cadence RunsCadence Runs BN run only, fullBN run only, full
distancedistance
Brigade run onlyBrigade run only
at prescribedat prescribed
distance,distance, BN RunBN Run
- qtrly- qtrly

43. D
RA
FT
Janurary 2004
AdditionsAdditions
 Runs at Change of CommandsRuns at Change of Commands
 Brigade run one/yrBrigade run one/yr
 Battalion run one/quarter (2/7 mi, 20-Battalion run one/quarter (2/7 mi, 20-
30 min)30 min)
 Beginning to incorporate RoadBeginning to incorporate Road
Marches into physical training,Marches into physical training,
building to a 20 lb ruck.building to a 20 lb ruck.

44. D
RA
FT
Janurary 2004
TimelineTimeline
1999 2000 2001 2002 2003
PresidentialMemoto
Secretaryof
LaborconcerningInjuryprevention.
2Jul1999
2004
AssessmentofProblem
Via
epidemiologicalsurveillance.
GeneralInjury
prevention
interventions
Targetedinterventions
232
ndBncontinued
Modifiedrunning
program
91-B course
changed to 91-W

45. D
RA
FT
Janurary 2004
91-B schedule vs. 91-W schedule91-B schedule vs. 91-W schedule
WeekWeek 11 22 33 44 55 66 77 88 99 11
00
11
11
11
22
11
33
11
44
11
55
11
66
91-B91-B DD
AA
PP
FF
TT
FF
AA
PP
FF
TT
91-W91-W DD
AA
PP
FF
TT
DD
AA
PP
FF
TT
DD
AA
PP
FF
TT
FF
AA
PP
FF
TT

46. D
RA
FT
Janurary 2004
• Using macroergonomic andUsing macroergonomic and
public health approachespublic health approaches
resulted in:resulted in:
– developing an environment conducive todeveloping an environment conducive to
implementing injury control initiativesimplementing injury control initiatives
– developing a network of individualsdeveloping a network of individuals
“dedicated to the cause”“dedicated to the cause”
– overall and targeted reductions inoverall and targeted reductions in
musculoskeletal injuries and lost dutymusculoskeletal injuries and lost duty
daysdays
– implementing changes which can lastimplementing changes which can last

47. D
RA
FT
Janurary 2004
SummarySummary
• The running template was designed as aThe running template was designed as a
conservative approach, which allowed soldiersconservative approach, which allowed soldiers
to improve performance incrementally, withoutto improve performance incrementally, without
developing musculoskeletal injuries.developing musculoskeletal injuries.
• Even with this cautious approach, performanceEven with this cautious approach, performance
gains were essentially equal between the Pre-gains were essentially equal between the Pre-
RT (traditional PT) and RT groups.RT (traditional PT) and RT groups.

48. D
RA
FT
Janurary 2004
RecommendationsRecommendations
• CommanderCommander’s Program’s Program
(baseline)(baseline)
• AccountabilityAccountability
• Standardize PTStandardize PT
• Do not leave PT up to individual discretionDo not leave PT up to individual discretion
• Decrease emphasis on endurance runningDecrease emphasis on endurance running
• Unit pass rates not PT scoresUnit pass rates not PT scores

49. They have to come to:They have to come to:
believe itbelieve it
live itlive it
teach itteach it
preach itpreach it
make it part of their daily lifestylemake it part of their daily lifestyle