Resilience feb 9 v1.4

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  • Jim Larsen [email_address]
  • Today’s IMT graduate may well be in contact with the enemy within 30 days of graduation. A single briefing, demonstration, or practice on “call for fire” , for example, is ineffective. Soldiers need high levels of practice to standard. Learning one task in isolation from the collective context can be equally ineffective. Shooting, throwing a grenade, or even treating a casualty can be quite different in the squad perimeter under even simulated fire vice doing it in a classroom.
  • As combat changes, we need to optimize our training. Everything must directly support WARFIGHTING. We face: Complex battlefield environments with multiple organizations and groups. The porous battlefield with no FLOT. Increasing system complexity and numbers of systems (look at the Soldier load!) Optimum tooth-to-tail (reduce system manning and maintenance requirements)
  • Traditional BRM model does not reflect dynamic combat. We are doing convoy live fire in BCT today as well as carrying blank-loaded weapons daily to train safe weapon handling. Perhaps the future Combat Marksmanship range will score killing “tough,” moving, shoot-back targets on a fire-team maneuver range. Even a defensive BRM range perhaps ought to have aiming stakes, range cards, defiladed targets, and a OPORD/FRAGO with ROE
  • 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.
  • You can see the impact of an optical sight and better ammunition on longer range engagements. The human eye cannot focus in 3 planes and the WWI peep sight is slow and obscures the target. If this was a maneuvering shooter against a shooting, moving target, I think we can imagine what the comparison might look like. Human engineering and high fidelity training combine to make more kills.
  • 42. Haisman, M.F. and R.F. Goldman. Effect of terrain on the energy cost of walking with back loads and handcart loads. J. Appl. Physiol. 36:545-548, 1974. 43. Haisman, M.F., F.R. Winsmann and R.F. Goldman. Energy cost of pushing loaded handcarts. J. Appl. Physiol. 33:181-183, 1972. 48. Harman, E.A. and P.N. Frykman. Heavy load carriage performance correlates: backpack vs. individual towed trailer. Med. Sci. Sports Exerc. 27:S136, 1995. 140. Vanderlaan, J.C., R.C. Turlington and D.N. Tarter. Combat load cart (MANCART). Ft Lewis, WA: Army Development and Employment Agency Report No. ADEA-AR-88-A214, 1988. Effects of a Specifically Designed Physical Conditioning Program on the Load Carriage and Lifting Performance of Female Soldiers. Authors: Everett Harman; Peter Frykman; Christopher Palmer; Eric Lammi; Katy Reynolds; ARMY RESEARCH INST OF ENVIRONMENTAL MEDICINE NATICK MA
  • http://www.zeppelin-systeme.de/medicarestarte.htm http://www.johnsonmedical.com/Mobile%20Solutions%20Brochure.pdf http://www.towerworx.net/solutions.htm
  • 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.
  • Introduction (cont ’d)
  • 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.
  • 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.
  • 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.
  • 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.
  • 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%
  • How DCG-IMT might prepare, support, and sustain AMF in FSO
  • Resilience feb 9 v1.4

    1. 1. Resilience “Training for warfighting is our number one priority in peace and in war. Warfighting readiness is derived from tactical and technical competence and confidence. Competence relates to the ability to fight our doctrine through tactical and technical execution. Confidence is the individual and collective belief that we can do all things better than the adversary and the unit possesses the trust and will to accomplish the mission.” FM 7-0, Training the Force04/10/13 1
    2. 2. ROE 1. There is no brick wall between the brain and the body. Each affects the other. 1. Correlations may be indicators, but are not always causes. Everyone sees people die; everyone watches forensics pathology and horror/monster shows. 1. Military personnel come from the civilian community. Civilian data lags by 4-6 years and similar problems are likely increasing there as well (32,000 civilians commit suicide/year). 2. Disease progression can be gradual with small early symptoms before large overt symptoms. 3. PTSD may be a multi-factor syndrome; even if one factor ‘started’ the PTSD, it may cascade into more serious dysfunction with other contributing factors. 4. A FOB-based asymmetrical war means no front line and no secure rear area (support manpower and organization structure are based on those). How do Preventive Medicine teams or Chaplains function?04/10/13 2
    3. 3. What is resilience?04/10/13 3
    4. 4. Resilience Resilience: The resources to withstand, recover and/or grow in the face of stressors and changing demands. Resilience: The resources to withstand, recover and/or grow in the face of stressors and changing demands. CHAMP, USUHS CHAMP, USUHS Improving the cognitive agility, flexibility, and capacity of Expeditionary Warriors (EW) by making them mentally tough, Improving the cognitive agility, flexibility, and capacity of Expeditionary Warriors (EW) by making them mentally tough, resilient to stress, and well adapted to chaotic, irregular environments. USMC R&D resilient to stress, and well adapted to chaotic, irregular environments. USMC R&D When hurt or distressed, resilient people expect to find a way to have things turn out well. They feel self- When hurt or distressed, resilient people expect to find a way to have things turn out well. They feel self- reliant and have a learning/coping reaction. Albert Siebert, Ph.D., The Survivor Personality. reliant and have a learning/coping reaction. Albert Siebert, Ph.D., The Survivor Personality. Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress …. It means ‘bouncing back’ from difficult experiences. APA, The Road To Resilience. sources of stress …. It means ‘bouncing back’ from difficult experiences. APA, The Road To Resilience. The United States Olympic Committee found that human performance at elite levels is heavily dependent upon The United States Olympic Committee found that human performance at elite levels is heavily dependent upon intangible, mental factors, i.e. confidence despite setbacks, concentration amidst distractions, and composure intangible, mental factors, i.e. confidence despite setbacks, concentration amidst distractions, and composure during times of stress. during times of stress. Battlemind – the Soldier’s inner strength to face fear and adversity in combat with courage. It is “Soldier-speak” for Battlemind – the Soldier’s inner strength to face fear and adversity in combat with courage. It is “Soldier-speak” for hardiness and resilience. www.battlemind.org hardiness and resilience. www.battlemind.org Time management, command of the basics, skill mastery, combat focus, visualization, repetition, and the use of job Time management, command of the basics, skill mastery, combat focus, visualization, repetition, and the use of job aids to be the most critical training that prepared Soldiers for efficient and effective task accomplishment under life- aids to be the most critical training that prepared Soldiers for efficient and effective task accomplishment under life- threatening, fast-paced, and stressful conditions. ARI – Infantry Forces Research Unit threatening, fast-paced, and stressful conditions. ARI – Infantry Forces Research Unit Resilience -- the process of adapting in the face of adversity, trauma, tragedy, threats, or other significant sources of distress Resilience the process of adapting in the face of adversity, trauma, tragedy, threats, or other significant sources of distress (combat). COL Cornum (combat). COL Cornum04/10/13 “Teamwork is 70% of combat performance.” COL Mike Malone 4
    5. 5. BATTLEMIND www.battlemind.org Battlemind – the Soldier’s inner strength to face fear and adversity in combat with courage. It is “Soldier-speak” for hardiness and resilience… Key components include: – Self-confidence • Take calculated risks • Handle future challenges – Mental toughness • Overcome obstacles or setbacks • Maintain positive thoughts during times of adversity and challenge. COMMANDERS - through good training and good leadership - enhance resilience in Soldiers and units. COL Cornum04/10/13 5
    6. 6. American Psychological Association Post Traumatic Growth Potential: • Relating to Others: People who experience trauma typically develop stronger bonds with loved ones, reestablish relationships, and/or gain more compassion for others. • New Possibilities: People who experience trauma may notice they are making choices in a more conscious manner, according to a plan. May be more likely to change things that need changing. • Personal Strength: People who experience trauma often express greater self- reliance, and feel more able to accept how things turn out. Find increased personal strength that may help get them through hardships they encounter in the future. • Spiritual Change: People who experience trauma may reevaluate spiritual beliefs, associate more with a community of similar believers, or reconnect with their spiritual roots. • Appreciation of Life: People who experience trauma typically describe greater appreciation of life. Some explain this as trying to live each day more fully. Some may rethink their values and priorities about what is important in their life.04/10/13 6
    7. 7. What degrades resilience?04/10/13 7
    8. 8. Civilian Population • 40% come from ‘non-traditional’ homes without two consistent parenting figures. • 40% come from ‘non-traditional’ homes without two consistent parenting figures. • 19% of HS students had seriously considered attempting suicide during a 12 month • 19% of HS students had seriously considered attempting suicide during a 12 month period. period. • 8% of HS students reported making a suicide attempt in the preceding 12 month • 8% of HS students reported making a suicide attempt in the preceding 12 month period. period. Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, WRAIR • ≅400,000 adolescents and young adults were treated for self-inflicted injuries in 2006 • children and adolescents hospitalizations for depression….. increased by 27 percent between 1997 and 2007. • ≅20 percent of individuals self-injure at least once, and about 11 percent self-injure repeatedly (in high school and college). Source: Theodore Beauchaine, Associate Professor of Psychology, Director, Child and Adolescent Adjustment Project, University of Washington.04/10/13 8
    9. 9. Leading Causes of Mortality Leading Causes of Mortality Among 15-24 Year-olds Among 15-24 Year-olds Other Causes 23% HIV Infection 2% Other Injuries 9% Suicide 14% Motor Vehicle Crash 31% Homicide 21% - Behaviors that result in unintentional and intentional injuries - Alcohol and drug abuse - Sexual behaviors that result in HIV infection, other STDs, and unintended pregnancy04/10/13 Source: CDC 9
    10. 10. 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. USMC National 2. Associated high-risk behaviors (sex, Sample Samples drugs, smoking, etc.) Men Women Men Women 3. Associated impacts (health, disease, poor job performance, depression, Child 26.7 38.3 3.2 4.8 etc.). physical 4. Diminished brain development. Child 14.7 51.0* 3-16 12-27 5. Treatable. sexual *Wolfe, J. (1996-2000). Adaptation to First-Term Enlistment Among Women in the Marine Corps. DAMD 17-95-1-5047.04/10/13 10
    11. 11. Adverse Childhood Experiences (ACE) Adverse Childhood Experiences (ACE) are Common in Civilian and Military Populations 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% Note: Data does not adjust for differences in population demographics. • 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). • Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, WRAIR04/10/13 11
    12. 12. WWII had very high Combat Stress casualties. WWII had very high Combat Stress casualties. Causes: Causes: •• Physical exhaustion. Physical exhaustion. •• inadequate food. inadequate food. •• Inadequate equipment. Inadequate equipment. •• Severe cold/heat. Severe cold/heat. •• Poor rotation policies (>180 days in combat). Poor rotation policies (>180 days in combat). •• Limited doctrine/Lessons Learned. Limited doctrine/Lessons Learned. •• Poor training. Poor training. •• High casualty rates. High casualty rates. •• Hospitalizing Soldiers and sending them home with disability benefits. Hospitalizing Soldiers and sending them home with disability benefits. Sources: •GEN DePuy, “Oral History” •Ambrose, “Citizen Soldiers.”04/10/1312 •FM 6-22.5, Combat Stress
    13. 13. 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.04/10/13 13
    14. 14. Unintended Side-Effects Mefloquine and mental health problems among U.S. military personnel. R. L. Nevin (13 January 2010). http://www.bmj.com/ To reduce the risk of serious adverse events including anxiety, paranoia, depression, hallucinations, and psychosis, mefloquine is contraindicated among those with certain prevalent neuropsychiatric disorders. Among the 4,505 to whom mefloquine was prescribed in this study, 155 (3.4%) had documented contraindications. Among those with documented contraindications, mefloquine was indeed inappropriately prescribed to 1 in 7. The U.S. package insert cautions that “during prophylactic use, if psychiatric symptoms such as acute anxiety, depression, restlessness or confusion occur, these may be considered prodromal to a more serious event. In these cases, the drug must be discontinued". Given that approximately 3.4% of those prescribed mefloquine in this study had evidence of psychiatric symptoms even prior to beginning prophylactic use, and may have been exposed to mefloquine for the duration of combat deployments lasting as long as 15 months, it is reasonable to conclude that this inappropriate prescribing may have led to a number of "more serious" events within this population. It seems reasonable to conclude that the inappropriate prescribing of mefloquine to those at risk of serious adverse events must in some measure be contributory to the current burden of serious mental health disorders among U.S. military personnel.04/10/13 14
    15. 15. What contributes to resilience?04/10/13 15
    16. 16. Building Resilience 1. Connect with family and friends. Stay connected with your family and friends who care about you and will listen to you; they will help you stay strong. Write letters so you’ll get letters. Call, text, or e-mail friends and family whenever authorized. 2. Keep things in balance. You can change how you feel about events. Try to see events as opportunities. Is this event really the “end of the world?” One way to calm yourself is to: take three deep breaths, tense all your muscles for a ten- count, then relax (It helps). Learn what triggers you getting upset, then mentally practice a more effective future response. Somebody call you a name you don’t like? Practice making a joke out of it. 3. Value change. Change is part of growing up and becoming an adult. Change can have a positive impact on you. Your attitude can help you find the “silver lining in the cloud.” You may have sore muscles when you exercise, for example, but you’ll also be getting stronger every week. 4. Keep your eye on your goals. Develop small goals within your big goals. Whats one thing you can do better today? Whatever you want to be in life, you’ll have to spend hundreds of hours learning your new skills. There will be days when you feel frustrated or things seem impossible. Think about where you want to go in life. Whether you want to get a good job or go to college, your short time in the current situation helps you get to that goal. 5. Take positive corrective action. Take positive action to fix the problem. Even if the issue is not immediately solvable, doing positive things for yourself also helps. Write a letter, talk to somebody, etc. Even making a “To Do” list helps. Go for a run. One positive action is to ask for help. The Army has resources who can help with problems (talk to your NCO). 6. Grow from experiences. You may find you’ve gotten stronger from a struggle; that working hard and overcoming obstacles makes you feel better about yourself. How can you do better next time? Make a mistake (and we all make mistakes)? How can you fix it? 7. Believe in yourself. Say positive things about yourself. “I’m a survivor.” “I can adapt, overcome, or improvise to win in a tough situation.” “I like learning new things.” Develop confidence in your ability to solve problems. Just as an example, you are one of the brightest and best Americans who are able to serve the Nation. 8. Take care of you. An “empty pitcher can’t pour milk.” Sleep, food, and water are critical to thinking clearly. Avoid making an important decision when you’re tired, hungry, angry, or sad. Not hungry? Don’t like the new food? Eat something you do like. Eat something anyway. Guess what? Your food tastes will change in a few days. 9. Ask for help. People make sacrifices for things or people they believe in, just like your parents did for you. What do you believe in? Go to church. Develop your spirituality; pray or meditate. Talk to your Battle Buddy. No one is alone in the Army; there are Chaplains, counselors, doctors, or experts in some area (pay, family resources, etc.) who can help. The team is stronger than the individual.04/10/13 Modified from the APA Resilience paper. 16
    17. 17. Building Resilience: APA factors that support the development of resilience • Influence of at least one (1) supportive person • Presence of hope and optimism in the face of adversity • Pleasant, active, social, nurturing, competitive personality • Problem-solving skills with eagerness to learn and succeed • View of self as victor instead of victim • Has something (friend, hobby, interest) that can distract • COL Cornum’s factors that support developing resilience: – Prior experiences/ training- Soldier has confidence – History of success- Soldier expects to do well in new activities04/10/13 17
    18. 18. Warrior Team High-fidelity RESILIENCE Optimum team-based man-machine interface targeted training Nutrition Fatigue Skill sets Environmental Health Support ARI – Infantry Forces Research Unit, found time management, command of the basics, skill mastery, combat focus, visualization, repetition, and the use of job aids to be the most critical training that prepared Soldiers for efficient and effective04/10/13 task accomplishment under life-threatening, fast-paced, and stressful conditions. 18
    19. 19. High-fidelity Team-based High-fidelity Team-based Optimum Soldier-machine Optimum Soldier-machine Targeted Training Targeted Training Warrior Team interface interface Warrior Team •Collective-based resident training •Collective-based resident training •Optical sight with Range Finder, auto •Optical sight with Range Finder, auto •Unit-level CTC •Unit-level CTC RESILIENCE RESILIENCE up-down, auto ballistic drop/range and up-down, auto ballistic drop/range and •Warrior Team PT •Warrior Team PT predictive lead. predictive lead. •Warrior Team Marksmanship •Warrior Team Marksmanship •Adaptive thinking (ARI) •Adaptive thinking (ARI) •Positive leadership model •Positive leadership model Fatigue Fatigue Nutrition •Rotation policies (CONOPS) •Rotation policies (CONOPS) Nutrition •Modified load (see load brief) •Modified load (see load brief) •Comprehensive testing program •Comprehensive testing program •Mancart R&D (see Harman et al) •Mancart R&D (see Harman et al) •Evidence-based diet •Evidence-based diet •Hot resupply R&D •Hot resupply R&D •Access within OPTEMPO •Access within OPTEMPO •Sleep restore R&D •Sleep restore R&D •Warrior bar && drink •Warrior bar drink •Wet combat rations R&D •Wet combat rations R&D Resilience Skills Resilience Skills Environmental Environmental •Success Profiler R&D •Success Profiler R&D •Rapid acclimatization training •Rapid acclimatization training •Embedded resilience in training •Embedded resilience in training •Chilled IV ++ supplements R&D •Chilled IV supplements R&D •Soldier-wearable digital WBGT R&D •Soldier-wearable digital WBGT R&D •Microclimate hat-vest (ongoing) •Microclimate hat-vest (ongoing) Health Health •Outdoor evaporative cooling R&D •Outdoor evaporative cooling R&D •CONEX-based force (see brief) •CONEX-based force (see brief) •Integrated medicine policy •Integrated medicine policy •Anti-inflammatory diet (see nutrition) •Anti-inflammatory diet (see nutrition) •Comprehensive blood- tissue testing •Comprehensive blood- tissue testing (NAHANES +) (NAHANES +) •Injury RM Program •Injury RM Program •Enhanced HCP musculo-skeletal treat •Enhanced HCP musculo-skeletal treat skills (see USMC SMIP) Support Support skills (see USMC SMIP) •Mefloquine R&D •Mefloquine R&D •CONEX-Based Force •CONEX-Based Force •Multi-disciplinary rehabilitation doctrine •Multi-disciplinary rehabilitation doctrine •MWR-DFAC-Commissary-AAFES/BX- •MWR-DFAC-Commissary-AAFES/BX- (TRADOC copy) (TRADOC copy) Ed Svcs family programs Ed Svcs family programs •ACE screening R&D •ACE screening R&D •Deployed spouse education program •Deployed spouse education program •Boot engineering stds R&D •Boot engineering stds R&D04/10/13 19
    20. 20. Warrior Team Resilience High-fidelity Team-based High-fidelity Team-based Warrior Team Resilience Targeted Training Targeted Training •Collective-based resident training •Collective-based resident training •Unit-level CTC •Unit-level CTC •Warrior Team PT •Warrior Team PT We’ve been here before •Warrior Team Marksmanship •Warrior Team Marksmanship •Adaptive Thinking (ARI) •Adaptive Thinking (ARI) •Positive Leadership •Positive Leadership We’ve done this before We know how to do this well We have confidence in ourselves and our leaders Our team can win04/10/13 20
    21. 21. Teamwork: Soldier-Collective Task Integration Teamwork: Soldier-Collective Task Integration • As much as 70% of unit performance can be teamwork. • Train Soldier tasks in collective context. • Provide CTC-like capabilities by level in IMT & units. • Design training courses backwards from collective tasks. • Create joint, combined, and multi-national training opportunities. • If the organization goes to war (e.g. Red Cross, CIA, AAFES/BX, MWR, etc.), it should participate in the training base as appropriate by level.04/10/13 21
    22. 22. Prepare, support, and sustain FSO Prepare, support, and sustain FSO Train Modular Force for Full Spectrum Operations (FSO) • Teamwork: Soldier-Collective Warrior Task Integration • Cultural awareness and languages • Positive Leadership • Adaptive Thinking • Tools: Combat Leader’s Guide • Warrior Team Fitness • Warrior Team Marksmanship04/10/13 22
    23. 23. Onsite, mission-specific training:CONEX-Based MOUT/ Unit-Based Combat Training Centers) http://www.uxb.com/products/training/ratpac.cfm http://www.militarywraps.com/
    24. 24. StrengthStamina Warrior Team FitnessSkill Phase 2: Warrior Team PhaseSpeedSpirit Reverse course as 4-Soldier litter carry with sandbag casualtySuppleness Trains teamwork, strength, and skillTeamwork Scored on both time and doctrinal process Aerobic: Combat loaded march to time & distance standard with military events enroute (react to ambush, etc.) Not to C4 scale pit laser target C4 pit 2.5 ton low crawl low dry high 3 sec burst 4 soldier Mount wall gulch wall up-down litter (Option: cross cross cross assault carryambulance load)04/10/13 24
    25. 25. Warrior Team Marksmanship Warrior Team Marksmanship • Strong issue that affects confidence. • Integrated rifle-optics-ammunition-targets-training strategy • Targets: • Simple, deployable targets (kill-reset) • Rocking or moving • Physiologically-based kill zone scoring • Shoot-back targets (Simunition©) • Ballistic mass requiring multiple hits • Fire and maneuver CTC-like ranges • Possible high-low standards/equipment mix by MOS Does combat look like this? Body armor, helmet, rifle, and vehicle interfaces can be critical04/10/13 25
    26. 26. Warrior Team Marksmanship Warrior Team Marksmanship High targets The Fire Team fighting range presents multiple targets and scenarios that require accuracy, fire & movement, teamwork, tactics, and problem solving. Targets can pop-up, move, and simulate shooting back. Civilian Don’t Shoot target C4 pit AK47 & RPG Muzzle-flash targets targets Friendly 3 sec up-down target assault Range not to 4-shot scale kill Shoot-through Cover target high C4 pit wall cross grenade throw • The Fire Team fighting range should be a slice of combat terrain, scenarios, target mix (aspect, distances, behavior), and teamwork. Shooting accuracy, speed, lethality, low weapon handling, and positional awareness are all worked into a ‘crawl-walk-run’ wall training matrix. cross • Even today’s KD ranges should be an accurate slice of the defensive perimeter with Fire Team correct fighting positions, obstacles, etc. Start Point 26DETECT-DECIDE-DESTROY • Always do it right so Soldiers see it right.
    27. 27. 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: ARI04/10/13 Training critical thinking works! 27
    28. 28. 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 aids04/10/13 28
    29. 29. IET OES NCOES WOES UNIT By Compo MANUALS FUTURE SOLDIER TRAINING ROTC PRE-COMMISSIONING Future Soldier Guide PROGRAM Basic Officer Leader Course Perform Pre-BCT Battle (BOLC I) Stress/Battlemind CM Perform Battle Stress/Battlemind TSP CM Video on web TSP Poster 1 DVD BCT/OSUT 1-3 BOLC 2 WOCS Annual Trng (AR 350-1) SMCT x Perform BCT Battle Implement Battle Perform Battle Stress/Battlemind DL-based interactive video Stress/Battlemind CM Stress/Battlemind CM CM TSP DVD Poster 2 OSUT 4-6/AIT BOLC 3 WOBC PCC Perform OEF/OIF Battle Implement Battle MEL 7 Implement Battle Stress/Battlemind Programs Stress/Battlemind Programs Implement Battle Stress/Battlemind Programs Stress/Battlemind Programs Warrior Leaders Course (WLC) PCC SMCT Y (former PLDC) Implement Battle Implement Battle Stress/Battlemind Programs Integrated Battlemind, Resilience, Combat Stress, Suicide Prevention, CONOPS, Stress/Battlemind CM & Helping Resources Training Strategy By Level (TBD) CPT CAREER CRSE BNOC WOAC PRE-DEPLOYMENT Implement Battle Implement Battle MEL 6 Perform Battle Stress/Battlemind Stress/Battlemind Programs Stress/Battlemind CM Implement Battle CM Stress/Battlemind Programs ANOC POST-DEPLOYMENT Implement Battle Perform Battle Stress/Battlemind Stress/Battlemind Programs CM Small-Group Intermediate Level Education Battlestaff NCO WOSC PROF DEV ANNUAL (ILE) Implement Battle MEL 4 Implement Battle (formerly CGSC) Stress/Battlemind Programs Implement Battle Stress/Battlemind Programs Supervise Battle Stress/Battlemind Programs Stress/Battlemind Programs First SGT Implement Battle Stress/Battlemind Programs WAR COLLEGE SMC WOSSC Supervise Battle Supervise Battle MEL 1 Stress/Battlemind Programs Stress/Battlemind Programs Supervise Battle04/10/13 Stress/Battlemind Programs 29
    30. 30. Warrior Team Resilience Optimum Soldier-Machine Optimum Soldier-Machine Warrior Team Resilience Interface Interface •Optical sight with Range Finder, auto •Optical sight with Range Finder, auto up-down, auto ballistic drop/range and up-down, auto ballistic drop/range and predictive lead. predictive lead. High Pay-off: Optical Smart Sight •laser rangefinder •auto uphill-downhill adjustment •auto ballistic drop/range •predictive lead •Night Vision compatible •add-on modular magnifier •BOIP TBD 80% of enemy casualties are from small arms fire. 475m 30% of the force does 80+% of the shooting. Successful performance = confidence04/10/13 30
    31. 31. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface Why adjustability? • The more these two folks at left contort themselves to conform to one weapon, the less performance you’ll see in combat (even if they shoot well in BRM). • The array of equipment options (weapon accessories, uniform, coats, gloves, arm/knee pads, LBE, IBA, helmet, etc.) requires a high degree of adjustability. DETECT-DECIDE-DESTROY04/10/13 31
    32. 32. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface Why shift to optical sights? • Multi-spectrum combat. Illumination/designation/sensing by energy spectrum band. • Human eye can only focus in one plane (not 3 planes for the iron peep sight). • Easy to train. Easy to remember. • Faster engagements (put dot on target; shoot). • Increased accuracy (especially at longer ranges), lead on moving targets. • Increased situational awareness (better view of target area). • Bypasses eye dominance issue. • Better performance with goggles, gas masks, etc. DETECT-DECIDE-DESTROY Eye Dominance Right-handed-left eye dominant 28.6% Left-handed-right eye dominant 3.9% Cross-dominant Total 32.5% Rengstorff, 196704/10/13 32
    33. 33. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface Why optical sights? • Human eye only focuses in one plane. • Peep sight field of view is narrow & tends to obscure the target. • Optical sight yields wide view and can provide ranging reference points. • Ex. Imagine you’re shooting at an enemy Soldier at 500m. • If you shoot center of mass, you’ll hit 45 inches low (3.75 feet). • How does the shooter apply Kentucky windage at 500M with the peep sight? M16A2 zeroed at 250m in hot weather. 3304/10/13 33
    34. 34. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface If you elevate the sight 45” above the target……04/10/13 34
    35. 35. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface Fast walking target (approx 4 mph) = 3 POA = 27” at 300 m Running target (approx 9 mph) = 6.9 POA = 62 ” at 300 m04/10/13 Source: USMC 35
    36. 36. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface Now line the lead up in shadow or at dusk or dawn.04/10/13 36
    37. 37. Optimum Soldier-Machine Interface Optimum Soldier-Machine InterfaceLead the Moving Target: • 25 yds: – 9 mph = 4.5” lead – 4 mph = 2” lead – Bad speed and range estimate can still hit target lethal area • 50 yds: – 9 mph = 9” lead – 4 mph = 4” lead – Bad speed and range estimate can miss target lethal area • 100 yds: – 9 mph = 18” lead – 4 mph = 8” lead – Misjudge speed by 3 mph misses target. – Misjudge range by 25 yds misses target. Data source: USMC 37
    38. 38. Optimum Soldier-Machine Interface Optimum Soldier-Machine Interface M16A2 10-Round Shot Group Extreme Spread 100 200 300 400 500 550 600 700 800 M4A1/ACOG 4x W/ MK 262 MOD 1 10-Round Group Extreme Spread 100 200 300 400 500 550 600 700 800 An optical sight and accurate ammunition makes a big difference*04/10/13 Firing was done from the shoulder on a bench * Source: NSWC 38
    39. 39. Warrior Team Resilience Fatigue Fatigue Warrior Team Resilience •Rotation policies (CONOPS) •Rotation policies (CONOPS) •Modified load (see load brief) •Modified load (see load brief) •Mancart R&D (see Harman et al) •Mancart R&D (see Harman et al) •Hot resupply R&D •Hot resupply R&D •Sleep restore R&D •Sleep restore R&D What contributes to resilience? Reducing Fatigue04/10/13 39
    40. 40. Reducing Fatigue In fact we have always done better by a mule than by a man. We were careful not to load the mule with more than a third of his weight.” The Soldier’s Load and the Mobility of a Nation, 1950, COL S.L.A. Marshall Combat Load: The minimum mission-essential equipment, as determined by the commander responsible for carrying out the mission, required for Soldiers to fight and survive immediate combat operations. The combat load is the essential load carried by Soldiers in forward subunits or the load that accompanies Soldiers other than fighting loads. (FM 21-18) Fighting Load: The fighting load includes bayonet, weapon, clothing, helmet, and LBE, and a reduced amount of ammunition. Keep under 48 pounds when cross-loading small unit equipment. (FM 21-18) Approach March Load: The approach march load includes clothing, weapon, basic load of ammunition, LBE, small assault pack, or lightly loaded rucksack or poncho roll. A limit of 72 pounds should be enforced. (FM 21-18) Emergency Approach March Loads: Circumstances could require Soldiers to carry loads heavier than 72 pounds such as approach marches through terrain impassable to vehicles or where ground/air transportation resources are not available. Therefore, larger rucksacks must be carried. These emergency approach march loads can be carried easily by well-conditioned Soldiers. When the mission demands that Soldiers be employed as porters, loads of up to 120 pounds can be carried for several days over distances of 20 km a day. Although loads of up to 150 pounds are feasible, the Soldier could become fatigued or even injured. If possible, contact with the enemy should be avoided since march speeds will be slow. (FM 21-18) “A load of 62 pounds or 40% of the body weight starts to collapse the venous return system.” Dr. Vogel04/10/13 Combat Load definitions are based on United States Army Field Manual 21-18, FOOT MARCHES, 1 June 40 1990.
    41. 41. ‘Reducing Fatigue’ History In 1987, the U.S. Army Development and Employment Agency proposed five approaches for improving soldier mobility: 1. Develop lighter weight components. However, technical developments were expected to reduce loads only by 6% overall (126). NOTE: Modifying the load to reduce the load or reduce energy cost might include: standardizing/consolidating batteries (see Wilcox Ind modified M4), solar battery charger, water filter pumps, reengineering the mortar base plate to be lighter & fold, etc.). 2. Soldier load planning model. This was a computer program that aided commanders in tailoring loads through a risk analysis based on the mission, enemy, terrain, troops and time (METT-T). 3. Development of specialized load-carrying equipment. This included such things as hand carts and all-terrain vehicles. NOTE: Offloading could include better hot resupply in danger areas. NOTE: Compared to body carriage, energy cost was reduced by 88% when a 50-kg load was pushed in a cart on a smooth surface (43). • Pulled carts (rather than pushed) appear to be easier to control on uneven terrain and also result in considerable energy cost savings (42). • A specially designed combat load cart that was pulled by soldiers using a hip belt resulted in faster march speeds than moving the same loads with a rucksack. Over mixed terrain (paved road, dirt road, field, and rough trail), 34-kg and 61-kg loads were moved 22% and 44% faster over a 3.2-km distance (48). This combat load cart, specifically developed for military operations, is available in the US Army. 4. Reevaluation of current doctrine that might affect load carriage. An example of this was an increased emphasis on marksmanship to reduce ammunition loads. NOTE: Caseless or aluminum cases would reduce ammo wt. Optical sights add weight, but improve accuracy (as does better training). 5. Development of special physical training programs to condition soldiers to develop more physical capability for load carriage. NOTE: Include a loaded march to time & distance std option vice running in PT program. NOTE : Select Soldiers big and strong enough to carry the load (load is a function of % body weight).04/10/13 41
    42. 42. ‘Reducing Fatigue’ History The training program proved effective. •The weight of boxes the -women could lift to three different heights improved between 30% and 47%. •After training, the average box- weight the women could lift onto a truck was 118 pounds, 81% of the Army male value. •The number of 40-pound boxes the women could lift onto a truck in 10 minutes increased from 106 to 140. •The number of 40-pound boxes that could be lifted off the ground, carried 25 feet and placed onto a truck increased from 53 to 62. •Vertical jump and standing long jump distance increased 20% and 15% respectively. •The speed at which a 75 pound backpack could be carried over a 2- mile mixed- terrain course increased from 3.4 to 4.4 miles per hour. •Before the training, only 24% of the women could qualify for very heavy Army jobs; after the training, 78% could qualify. Effects of a Specifically Designed Physical Conditioning Program on the Load Carriage and Lifting Performance of Female Soldiers. Everett Harman et al. USARIEM.04/10/13 42
    43. 43. ‘Reducing Fatigue’ History Avg. % Body Inf. Rifle Co. Avg. Pounds High Load High % Weight Average Fighting Load 63.08 35.27% 81.38 44.46% (<48 lbs.) Average Approach March 101.31 56.74% 127.24 78.26% Load (<72 lbs.) Average Emergency Approach March 131.74 77.82% 149.30 90.49% Load (120 lbs.) The Modern Warrior’s Combat Load - Dismounted Operations in Afghanistan April - May 2003, LTC Charles E.04/10/13 Dean, CALL Dean 43
    44. 44. Sleep 1. Teens need 8.5-9.25 hours of sleep each night. By mid 20s: 8 hrs. 2. Natural biological sleep period 11 pm – 8 am (Melatonin secretion). 3. 0400-0600 is peak time for subjective sleepiness. Inadequate sleep: Adequate sleep: • Decreases: • Improves: – Vigilance – Test scores – Cognitive performance – Knowledge Retention • Inconsistent logical reasoning skills – Disease resistance • Reduced short-term memory – Morale • Slower learning rate • Poor judgment – Grades • Decreases: – Negative mood (depressive symptoms) – Discipline problems – Immunity (more disease) – Depression – Attrition • Increases risk re: – Stimulant or alcohol use – Accidents, injury, and death – Stress hormone levels Degrading sleep degrades learning, mood, and health. Prof Mary Carskadon, Brown University04/10/1344 http://www.sleepfoundation.org/hottopics/index.php?secid=18
    45. 45. 04/10/13 45
    46. 46. 04/10/13 46
    47. 47. Load slide04/10/13 47
    48. 48. Warrior Team Resilience Environmental Environmental Warrior Team Resilience •Rapid acclimatization training •Rapid acclimatization training •Chilled IV ++ supplements R&D •Chilled IV supplements R&D •Soldier-wearable digital WBGT R&D •Soldier-wearable digital WBGT R&D •Microclimate hat-vest (ongoing) •Microclimate hat-vest (ongoing) •Outdoor evaporative cooling R&D •Outdoor evaporative cooling R&D •CONEX-based force (see brief) •CONEX-based force (see brief) •Anti-inflammatory diet (see nutrition) •Anti-inflammatory diet (see nutrition)04/10/13 48
    49. 49. Warrior Team Resilience Support Support Warrior Team Resilience •CONEX-Based Force •CONEX-Based Force •MWR-DFAC-Commissary-AAFES/BX- •MWR-DFAC-Commissary-AAFES/BX- Ed Svcs family programs Ed Svcs family programs •Deployed spouse education program •Deployed spouse education program04/10/13 49
    50. 50. 1.The ‘one box’ storage/shipping/functional container system concept enhances mission capabilities, meets world-wide shipping/ logistics standards (transportable via standard cargo container ships, cargo planes, helicopters, trucks or rail.), and saves significant time and resources. 2.It creates a nearly “instant” FOB, hospital, hospital ship, etc. capability. Requires no foundation. 3.Saves time and resources. Equipment/supplies are no longer packed/unpacked, loaded/unloaded, et. multiple times/places. 4.The conceptual basic military box (TBD) should be rust-proof, self-leveling, have standard interior wall interfaces for modular interior equipment, and have standard electrical/water/cable runs. Can be pre- insulated and solar power equipped. 5.Units are tough. Units can resist winds up to 100 mph without anchoring; and with anchoring, they can resist winds up to 175 mph. Can be stacked 30 high. 6.Armored/insulated onsite with local materials (e.g. Hesco barriers; see BU slide). 7.Units can pre-load supplies/equipment (weapons, ammo, rations, beds, etc.) in the squad ‘box,’ for example, to support the first 30-60 mission days. 8.Saving energy & labor is a force multiplier that saves transport costs and reduces exposure to the enemy (each FOB is basically an ‘island’ that imports everything).12/23/09 50
    51. 51. What contributes to resilience? Support04/10/13 51
    52. 52. Amount of support makes a difference Amount of support makes a difference Chaplain Medics Team Leaders Friends Influencers Family04/10/13 52
    53. 53. The Invisible Enemy: Boredom MWR MWR Red Cross Red Cross Education Education AAFES/BX AAFES/BX Services Services Commissary Commissary ACS? ACS?04/10/13 53
    54. 54. Combat Chaplain: Force Multiplier • Chaplains are critical assets. • Commander’s forward sensor. • Positive group sessions • Try this: Observe USMC Boot Camp Sunday session • Resilience message • Singing & music • Real-time on-the-ground ‘therapy.’ • Find work-arounds to legal issues (e.g. morale class vice church service).04/10/13 54
    55. 55. Warrior Team Resilience Nutrition Nutrition Warrior Team Resilience •Comprehensive testing program •Comprehensive testing program •Evidence-based diet •Evidence-based diet •Access within OPTEMPO •Access within OPTEMPO •Warrior bar && drink •Warrior bar drink •Wet combat rations R&D •Wet combat rations R&D04/10/13 55
    56. 56. 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) NOTE: Study BCT menu governed by the 1985 AR 40-251/26/10 56
    57. 57. 04/10/13 57
    58. 58. Environment SchoolNOTE: 22% of schools sell name-brand FAST FOODSource: Public Policy Analysis & Education Center for Middle Childhood, Adolescent & Young Adult Health
    59. 59. Environment School• Vending machine accessibility: – Elementary Schools 26% – Middle Schools 62% – High schools 95%• Vending machine offerings tend to be: – High in fats, sugar and sodium. – Devoid of daily recommended nutrients found in fruits, vegetables, grains and proteins.
    60. 60. *1966-1970 – Adolescent data are for ages 12-17, not ages 12-19.Source: CDC, 2004d
    61. 61. 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 621/26/10
    62. 62. Warrior Team Resilience Resilience Skills Resilience Skills Warrior Team Resilience •Success Profiler R&D •Success Profiler R&D •Embedded resilience in training •Embedded resilience in training04/10/13 63
    63. 63. 04/10/13 64
    64. 64. Warrior Team Resilience Warrior Team Resilience Health Health •Integrated medicine policy •Integrated medicine policy •Comprehensive blood- tissue testing •Comprehensive blood- tissue testing (NAHANES +) (NAHANES +) •Injury RM Program •Injury RM Program •Enhanced HCP musculo-skeletal treat •Enhanced HCP musculo-skeletal treat skills (see USMC SMIP) skills (see USMC SMIP) •Mefloquine R&D •Mefloquine R&D •Multi-disciplinary rehabilitation doctrine •Multi-disciplinary rehabilitation doctrine (TRADOC copy) (TRADOC copy) •ACE screening R&D •ACE screening R&D •Boot engineering stds R&D •Boot engineering stds R&D04/10/13 65
    65. 65. Total Force Plus Life-Cycle Health Readiness System: Total Force Plus Life-Cycle Health Readiness System: Why Do We Need aaComprehensive Life Cycle System? * * Why Do We Need 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 66
    66. 66. Mileage, Mileage, Mileage1.In 2003 CHPPM collected pedometer data on 10 BCT companies for entire BCT cycles at Ft. Jackson.2.Average daily distance for the 63 days was 11.7+_4.4 km/day (M+_SD).3.During the 3-day FTX, daily distances were 16.2+_9.7 km/day.4.Overuse injuries are a dose-response relationship: more miles equals more injuries. 26 IDENTIFY HAZARDS / ASSESSS HAZARDS / DEVELOP CONTROLS / IMPLEMENT CONTROLS / SUPERVISE-EVALUATE
    67. 67. Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army Recruits 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 68
    68. 68. 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 691/26/10
    69. 69. 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.70 4. Lifetime of treatment.1/26/10
    70. 70. 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 71
    71. 71. 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 72
    72. 72. 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, walking731/26/10
    73. 73. 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 74
    74. 74. 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 75
    75. 75. Hypothesis Description Strength COA • Inhibits the uptake of glucose by the hippocampus. Hippocampal neurons don’t have enough energy to function. • Resilience & Anti-stress training. • Inhibits neurotransmitters; nerve cells can’t communicate with one another. People under heavy • Vitamin C (titrate to std) Stress- stress find it hard to concentrate and think clearly. test. Cortisol TBD Overload • Affects the limbic system (hypothalamus, thalamus, • CONOPS hippocampus, amygdala and the pituitary gland); countermeasures. governs emotion, hunger, thirst, body temperature, sleep, sexuality and memory. • Re-balancing blood chemistry & drug research. • Excess cortisol kills neurons over time by too much calcium influx into the cells. • Cooling • Hot environment causes inflammatory response. Cytokine • Anti-inflammatory diet • Worsened by inadequate hydration, diet, and cooling. Strong Overload • Anti-inflammatory Warrior • First symptom is brain/behavior/thinking dysfunction. electrolyte drink04/10/13 76
    76. 76. Hypothesis Description Strength COA • Worsens information processing, judgment, and mood • CONOPS (WRAIR). countermeasures. Sleep • Can present as temporary psychosis (Combat Strong • Rest. Deprivation Exhaustion). • Sleep restoration/re- • May lead to other problems (alcohol/drug abuse, risk- balancing blood chemistry taking, poor diet, etc.). & drug research. • Evaluate Success Profiler • Recruits come in with a wide variety of backgrounds dx test and training and skill sets. longitudinally, especially in high-risk groups. • JROTC uses the Success Profiler test and training. http://www.conovercompany.com/products/successe/ • Bibliography available. Skill Deficit Strong • In CDC Adverse Childhood Experience (ACE) study, • See Success OPORD brief 2/3 were high-risk while 1/3 were successful. Delta was largely an adult mentor who provided resilience • Chaplain combat-style skills. support in IET and units. • Thyroid deficiency, especially in middle-aged women • Comprehensive blood (>35), causes fatigue, depression, memory loss, etc. chemistry. Bio-chemical • Cholesterol imbalances affect health and thinking. • Improved autopsy. Strong Deficiencies − 1/5 of children have high cholesterol. • Re-balancing blood chemistry & drug treatment − Some 18 y/o RVN dead had 50% arterial occlusion. research.04/10/13 77
    77. 77. Hypothesis Description Strength COA • Severe nutritional deficiencies (B, C) linked to psychoses (Pellagra, Beri Beri, Scurvy). • Comprehensive blood • Iron, vitamin Bs, iodine, vitamin D, calcium, omega 3s, et al chemistry testing at entry deficiencies affect health, thinking, and mood. and career sampling. Nutritional • Military diet inadequate (USARIEM; Lappe Navy). • Evidence-based diet. Strong Deficiencies • Mediterranean Diet linked to health and mood. • Supplements titrated to effective serum levels. • Diet linked to adolescent behavior problems (Oliver; Schauss) • Improved autopsy. • Alkaline diet (+ vegetables) linked to effective nutrient uptake. •Mental health is not objectively screened for at entry. •CDC ACE study documents 2/3 child abuse survivors are at high risk. PET scans show under-developed corpus callosum (see also Harlow studies). These survivors may join the military at higher rates (Wolfe, J. (1996-2000). Incoming Adaptation to First-Term Enlistment Among Women in the • Screening research. Marine Corps. DAMD 17-95-1-5047) Strong Pathology •Child abuse survivors have lower levels of the NR3C1 gene expression, which affects ability to cope with stress (Nature Neuroscience). •PTSD vulnerability (poor physiological response to stress; remain hypervigilant neuro-endocrinologically after stressors).04/10/13 78

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