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Chapter 8 Primary Prevention of Injuries in Initial Entry Training

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Chapter 8 Primary Prevention of Injuries in Initial Entry Training Primary Prevention of Injuries in Initial Entry Training Chapter 8 PRIMARY PREVENTION OF INJURIES IN INITIAL ENTRY TRAINING † ‡ JOSEPH J. KNAPIK, ScD*; KEITH G. HAURET, MPT, MSPH ; AND BRUCE H. JONES, MD, MPH INTRODUCTION INJURY PREVENTION AND THE PUBLIC HEALTH MODEL Surveillance and Surveys Research Intervention Trials Program Implementation and Program Monitoring SUMMARY *Major, Medical Service Corps, US Army, Retired; Research Physiologist, Injury Prevention Program, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland 21010 †Lieutenant Colonel, Medical Specialist Corps, US Army, Retired; Epidemiologist, Injury Prevention Program US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland 21010 ‡Colonel, Medical Corps, US Army, Retired; Program Manager, Injury Prevention Program, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland 21010 125 Recruit Medicine INTRODUCTION Individuals who join the US Army enter a new and marching. These physical tasks put recruits at risk environment in which they face both physical and of injury, now a major concern of IET commanders. mental challenges.1,2 The first phase of a new recruit’s Injuries account for 5 to 10 times as many limited duty introduction to the Army, basic combat training (BCT), days as illness3 and are associated with 6% to 8% of all is where he or she learns basic soldiering skills, Army recruit attrition.4,5 Progress in identifying modifiable values, military customs and courtesy, and other in- risk factors for injury and the development of suc- formation critical to the transformation from civilian cessful prevention strategies began in the mid-1980s to soldier. Immediately after BCT, most soldiers enter with the application of epidemiological concepts and advanced individual training (AIT), which is specific analysis. These included classic epidemiological host– to the each military occupational specialty (MOS). In agent–environment relationships in BCT6–9 and specific some MOSs, such as infantry, artillery, armor, mili- statistical techniques (stratified chi-square, logistic re- tary police, and combat engineers, BCT and AIT are gression, and survival analysis) to identify injury risk blended into what is called “one-station unit training” factors and test injury-reduction interventions.10–15 (OSUT). BCT, AIT, and OSUT are collectively referred The chapter will review the literature on primary to as “initial entry training” (IET), the preliminary injury prevention in IET, covering work performed training in effective soldiering. in the US Army and other services as well as in the All phases of IET include a wide variety of physical basic training units of other countries. A public health tasks: field exercises; motor skills training; and vigor- model is used to present a systematic review of the ous physical training involving running, calisthenics, literature. INJURY PREVENTION AND THE PUBLIC HEALTH MODEL “Primary prevention of injuries” means taking ac- determine the effectiveness of interventions designed tion to avert injuries before they occur. The term “injury to reduce injuries. prevention” is somewhat of a misnomer because any During the second step, research, investigators physical task involves some risk of injury, and prevent- determine the causes of injury and identify factors ing all injuries is unlikely. However, “injury preven- placing individuals at risk of injury. The two types tion” is commonly used to distinguish primary injury of risk factors are intrinsic and extrinsic. Intrinsic risk prevention from injury control. Injury control involves factors are characteristics of the individual, such as reducing the severity of an injury, once it has occurred, gender, age, and physical fitness. Extrinsic risk factors by early detection and treatment.16 are part of the environment in which the individual The public health model offers a systematic is operating, such as training programs, equipment, methodology for addressing injury problems in five and weather. steps17–19: Once an injury problem is identified and causes and risk factors researched, the third step is intervention. 1. surveillance, surveys, or both, Intervention involves developing creative, practical 2. research, injury-reduction strategies, and then testing them for 3. intervention, their effectiveness. Intervention strategies might involve 4. program implementation, and modifying equipment, training procedures, or the 5. program evaluation. training environment through engineering, education, or development and enforcement of regulations. The first step in the injury-prevention process, sur- The fourth step, program implementation, involves veillance and surveys, is critical to determining the putting into practice the most effective injury-reduc- size of the injury problem. Surveillance is the routine, tion strategies developed in the intervention phase. In a systematic collection of data. Surveillance allows military environment, this “putting into practice” must tracking of injury rates and trends over time and alerts be accomplished by unit commanders. Commanders investigators to changes in injury rates. Where surveil- have the ultimate responsibility for integrating injury- lance systems have not been developed or where the reduction programs with mission accomplishment. specific data needed are not available within a surveil- The fifth and final step, program evaluation, seeks lance system, surveys can fill the gaps. Surveys deter- to determine the success of a program that has been mine injury incidence, rates, or both at specific times implemented in the operational environment. This is in specific groups. Surveillance and surveys provide usually achieved by comparing surveillance or survey baseline injury levels that can subsequently be used to data gathered before and after the implementation. 126 Primary Prevention of Injuries in Initial Entry Training Surveillance and Surveys trends, causes of injury hospitalizations, limited duty status, and anatomical location of injuries. An example Surveillance systems have recently been developed of an injury report for the entire Army is shown in for the routine tracking of IET injuries. Also, many Figure 8-1. IIRs do not specifically track recruits in injury surveys have been conducted that show IET IET, however, and provide information only on an injury prevalence and trends. Most surveys conducted entire service (Army, Navy, etc) or installation (Figure in IET involve systematic reviews of medical records, 8-2). AMSA also publishes the Medical Surveillance capturing specific pieces of information such as date Monthly Report (MSMR), which contains informa- of visit, diagnosis, days of limited duty, and final tion on specific injury issues often related to IET (also disposition.1,2,11 available at AMSA’s Web site). The second surveillance system, TRIR, was begun Surveillance of Injuries in Initial Entry Training by AMSA in 2003 to track training-related injuries in BCT. Injury rates are calculated using the International Four surveillance systems have been developed to Classification of Diseases, 9th revision (ICD-9), codes track injury information: for overuse injuries of the lower extremities. New injury cases (numerators) from AMSA are linked with 1. Installation Injury Reports (IIRs) from the De- personnel data (denominators) provided by the US fense Medical Surveillance System (DMSS), Army Training and Doctrine Command (TRADOC) 2. Training-Related Injury Reports (TRIRs), to produce monthly injury rates. These rates are ex- 3. Physical Training and Rehabilitation Program clusively for BCT units at each of the five posts where Surveillance System (PTRPSS), and BCT is conducted (Fort Jackson, South Carolina; Fort 4. Aberdeen Proving Ground Injury and Illness Leonard Wood, Missouri; Fort Benning, Georgia; Fort Surveillance System (APGIISS). Sill, Oklahoma; and Fort Knox, Kentucky). Figure 8-3 shows an example of the monthly report sent to the To compile IIRs, DMSS obtains inpatient and outpa- TRADOC surgeon’s office. tient data on injuries and diseases from military hospi- The third surveillance system, PTRPSS, was tals and clinics. IIRS are available at the Army Medical developed by the Physical Therapy Department at Surveillance Activity (AMSA) Web site (http://amsa. Moncrief Army Community Hospital, Fort Jackson, army.mil). The reports provide information on injury in 1998. The Physical Training and Rehabilitation a 300 225 150 75 0 Oct 2002 Jan 2003 Apr 2003 Jul 2003 Oct 2003 Jan 2004 Apr 2004 Injuries Per 1,000 Soldiers b 300 Army 225 Department of Defense 150 75 0 Oct 2002 Jan 2003 Apr 2003 Jul 2003 Oct 2003 Jan 2004 Apr 2004 Injuries Per 1,000 Soldiers Fig. 8-1. Trends in incident injuries for the entire US Army tracked by the Defense Medical Surveillance System. (a) Rate of injury in the Army. (b) Rate of injury in the Army compared to the Department of Defense. During February 2004, 34,661 of 487,505 soldiers (7.1%) had an injury requiring medical attention. Reproduced from: Defense Medical Surveillance System, Army Medical Surveillance Activity. Aberdeen Proving Ground, Md: US Army Center for Health Promotion and Preventive Medicine; 2004. 127 Recruit Medicine a 300 225 150 75 0 Injuries Per 1,000 Soldiers Oct 2002 Jan 2003 Apr 2003 Jul 2003 Oct 2003 Jan 2004 Apr 2004 b 300 Fort Jackson 225 Army 150 75 0 Injuries Per 1,000 Soldiers Oct 2002 Jan 2003 Apr 2003 Jul 2003 Oct 2003 Jan 2004 Apr 2004 Fig.
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