injuries & re-injuries are a significant issue that affect recruiting and force manning

1. Manning The Force:
Injury-Attrition Prevention
Options
V 2b3
Unofficial
OBJECTIVES:
• Increase eligible population
• Increase graduation rates
• Maintain high readiness rates
• Minimize injuries and attrition while maintaining standards

2. •ASVAB
• HS
• Test Sites
Training
• Vaccinations
• Red Cross
blood donation
• Specialty physicals
• Vision
• Hearing (MOS)
• Blood typing
• DNA
• Dental readiness
• Pregnancy
• Some Svcs:
• Chlamydia (10% +)
• SCT (risk for heat inj)
MEPS
• ASVAB
• Physical
• Qualify
• Oath
• Contract
• Travel
• HIV
• DAT
• Vision
• Hearing
• Conditions/diseases
• Functional (ortho-neuro)
• Ht-Wt (BF%)(Svc Specific)
• Pregnancy
AS-IS PROCESS
Unit
SDDC
USAREC
• Med Pre-screen
• Post DEP
Specialty Physicals
• PT Assess (1-1-1)
DASD-
Access Policy
Access Med Stds
Working Group
(AMSWG)
AMSARA
(Access Med Stds
Analysis & Research
Activity)

3. Injury-Related Variable Issue
Counter Measures/Options
Considerations/Costs
Entry osteopenia
• Most stress fractures had osteopenia (80%M-
60%F)(Rivero, Navy)
• 20% of women had osteopenia (Lappe, Army)
• DEXA not predictive. pQCT best.
• Time is a factor. Bone remodeling takes 4 weeks.
• Where to screen? MEPS, USAREC, RECBN, FTU, PTRP?
• Where to treat? DEP, RECBN, FTU, 2 BCT, PTRP?
Entry nutrient deficiencies
• Iron (IOM, USARIEM, AF)(AF: 25%F-9%M)
• Multiple deficiencies (USARIEM)
• Plant-based diet (Moran)
• Ideal is a comp blood chemistry. Retail: $135 per.
• Where to screen? MEPS, USAREC, RECBN, FTU, PTRP?
• Where to treat? MEPS, USAREC, RECBN, FTU, PTRP?
Under-fitness
• Underfit entry associated with injuries (Sharp,
Knapik, East)
• OPAT screens out underfit. Reduces attrition 2%.
Post-entry training design
• Well-designed workload progression reduces
injuries (USAPFS, Jones, Knapik)
• ACFT improves
• Mid-BCT leg ‘rest’ week option
• Reduce training mileage option
• FTU option
• 2 BCT option (regular-long)
Post-entry malnutrition
• Malnutrition increases in training base
(USARIEM Westphal, McAdam, USARIEM
McClung)
• Performance bar provides some D and calcium
• Possible tailored bars (gender, deficiency, nutrients)
• ARIEM Reduction in Musculoskeletal Injury (ARMI) results in 4-5 years
• Improve diet study option or more bars across day
• Rapid nutrient normalization treatment(s) study
Pre-entry smoking
• Smokers have higher injury rates (Knapik,
Cowan)
• Smoking effects research/treatments/counter-measures
BMI
• BMI AMSARA
• Low BMI is a risk factor (Jones)
• Higher BMI entry stds study to expand recruiting population
• Possible multi-factor screen (BMI, step test, Cat x, etc.)
PTRP
• Rehabilitation program is effective but
significant losses (attrition, med
retirement)(Devlin, Scott, Hauret, Knapik)
• Earlier screening/treatment would likely help
• Better multiple-variable treatment would likely help
• PT/OT CDR, PT Tech/CAT as staff.
• In-house med/PT/gym resources.
• Physiatrist on staff (Physical Medicine & Rehabilitation Specialist)
• Education & relevant local AIT support (resilience, ASVAB, etc.)(see
2005 issues)
Fitness Training Unit
(FTU)(cancelled)
• Reduces attrition 1% (Knapik)
• Needs effective design & content (East)
• Test an improved FTU or integrated FTU-BCT (2 BCT)
Prevention/treatment
• Calcium-D supplement reduced stress fractures
20% (Lappe)
• Spotting rocking gait early reduced FNF (Short)
• Marching controls reduce injuries (Rice, Pope)
• Re-injury rate 350%
• Improve DS training
• Certified Athletic Trainers Plus Forward (more sports medicine &
nutrition training). New MOS?
• Improve Troop Medical Clinics (TMC)(fix forward)
• Enrich/broaden med specialty training (AMEDDC&S)(PT, OT, medic,
psych, etc.)

4. 4
RECBN
• Vaccinations
• Specialty physicals
• Vision
• Hearing (MOS)
• Blood typing
• DNA
• Dental readiness
• Pregnancy
 OPTIONS
 PT screen
 pQCT bone screen
 Comp blood chemistry
 Iron screen
 Initial treatment start
 Route to FTU/BCT13 training
option
 Validate improved PTRP
MEPS
• ASVAB
• Physical
• Qualify
• Oath
• Contract
• Travel
• HIV
• DAT
• Vision
• Hearing
• Conditions/diseases
• Functional (ortho-neuro)
• Ht-Wt (BMI)(Svc Specific)
• Pregnancy
 OPTIONS
 Post-DEP contract screens
 pQCT bone scan
 Comp blood chemistry
 Iron screen
PROCESS OPTIONS (DRAFT)
USAREC
• Med Pre-screen
• Post DEP Specialty Physicals
• PT Assess (1-1-1)
 DEP only options:
 DEP Guide: Diet guidance
 DEP Guide: PT guidance
 Issue multi-vitamin
 Issue Performance Bars
 Gender and deficiency specific bars?
 Screen to FTU/BCT 13 option
 Mail-in blood drop
 Local med contract (LabCorp)
 Organic medics
 hand pQCT (TBD)
 Telemedicine support
 School PT contract(s)/training
 Gym PT contract(s)/training
o Expand the market
 Enhanced incentive: improved full-cost
college bonus by critical MOS
 Higher BMI test
BCT 10 or OSUT
 Week 4 or 5 no running
 Alternating weekly event PT design (see Body For
Life schedule)
 Validated multi-variable injury Stds of Care/CPG
 Minimize marching mileage with local classrooms
 Validated menu on serum levels (expand hours?)
 4 or 6 Perf bar option (a 6 ‘meal’ day)
 Gender specific bar option
 Deficiency bar option
 Research accelerated deficiency treatments to
raise target serum levels
FTU/BCT 13
 Registered course
 pQCT screen
 Comp blood chemistry
 In-house Med treatment
 Validated POI
 Validated prehab PT
PTRP
 Rehab FM
 pQCT bone scan
 Comp blood chemistry
 Improved Stds of Care/CPG
 PT/OT CDR with nutrient, Active Release,
Graston Tech trng, etc.
 PT, PT/OT tech, CAT staff with extra
trng
 Local AIT option
 Ed Ctr support (resilience, life skills,
applied diet, ASVAB, etc.)
Options:
o Generally “prevention & fix forward” is optimum.
o Should be tailored/modified based on size, manpower, & cost effects.
o Should be tested/validated prior to full implementation
o Some ‘structural’ changes may be needed (organization
missions/AOR, med Specialty/MOS descriptions/training, FM, etc.).

5. MEPS Screen:
OPAT score
Or
BMI
Or
Combo
N= 80,000 AC
• Screen-in
higher BMI
• Assume
20%
identified at-
risk: 16,000
MEPS Iron screen #1
HemoCue 301 Machines
$100,000 (one time buy)
Supplies= $1/person
$16,000/year
CAUTION:
Improve data
Test concept first
Normal
88%
6,400
Mild-Mod
12%
9,600
*Severe
0.06%
48
GO
USAREC DEP
LABCORP
Comp Blood Chem
$100
$960,000/year
DQ
USAREC DEP
Treat
Telemedicine
contract
$500 ea
$4,800,000/year
#1 NOTIONAL AC PRE-IET SYSTEM
OBJECTIVE:
4% IET Attrit
50% injury reduction
Save > $250,000,000
Numbers are WAG
MEPS Ship day
Iron screen #2
Supplies= $1/person
$16,000/year
BCT
OSUT

6. MEPS Screen #1:
OPAT score
Or
BMI
Or
Combo
N= 80,000 AC
• Screen-in
higher BMI
• Assume 20%
identified at-
risk: 16,000
MEPS Iron screen #2
HemoCue 301 Machines
$100,000 (one time buy)
Supplies= $1/person
$16,000/year
Normal
88%
6,400
Mild-Mod
12%
9,600
*Severe
0.06%
48
DQ
Route to 3
week FTU+
#2 NOTIONAL AC PRE-IET SYSTEM
OBJECTIVE:
6% IET Attrit
50% injury reduction
Save > $120,000,000 (minus FTU costs)
Numbers are WAG
BCT
OSUT
CAUTION:
Improve data
Test concept first

8. 8
System View Platoon View
• The NCO is an important
decision-maker.
• ‘System View’ and
‘Platoon View’ are quite
different.

9. 9
IET
ATTRIT
ENTER
INJURED
UNIT
FIRST
TERM
ATTRIT
Where to make the investment?

10. 10
• 90% spend 90% time indoors
• 14% obese; 25% OW
• 75% not have regular fitness in HS
• 90% bused to school
• 75% less contact with adults
• Fast food diets
• Entry fitness down
• 25% from single parent families
• 63% from dual-income families
• 49% from mild-to-severe dysfunctional
families (ACE)(Adverse Childhood
Experiences)
• Linear relationship with ACE risk factors
and later health/adjustment problems
• Entry Fitness
• Entry Health
• Coping Skills
• Diet
• Bone strength
• Overfat
• ACE families
• T2 diabetes
• Asthma
1980 Today
Changing Teen Population

11. 11
Underlying Physiological Conditions
USARIEM BCT Study
• 1993 study of 174 women in an all-female 8-week BCT company at Fort Jackson, SC
(158 graduated).
• Serum ferritin (body iron stores) were low pre-BCT (56% females at less than
20 ng/ml iron) and decreased further by graduation (84%)(pg.109).
• Anemia was correlated with poor PT performance (pg. 111)
• Serum folate levels were low normal pre-BCT and “decreased significantly over
BCT.” (pg. 2)
• Maternal low folate intake and blood levels have been "associated with (fetal) neural
tube defects“ (pg. 39) (note: neural tube defects can be fatal for the fetus).
• Menu was adequate in energy, but inadequate in B6, folic acid, calcium, magnesium,
iron, and zinc.
• Source: “Health, Performance, and Nutritional Status of U.S. Army Women during
Basic Combat Training,” (1995)(ADA302042)
• NOTE: Study BCT menu governed by the 1985 AR 40-25
Poor iron levels affect thinking, mood, learning, bone strength, healing, and PT.