Total force health sys 26 jan 10

Jim Larsen

[email protected]

One Team; One Fight

Conserve the Fighting Strength

Total Force PlusLife-Cycle

Health ReadinessSystem

Total Force PlusLife-Cycle

Health ReadinessSystem

mailto:[email protected]

IssuesIssues

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1. Where are the ‘human performance’ boundaries? What do we include/exclude?

2. What are the measurable outcome criteria? Combat performance or health-wellness? Operational Readiness (OR) rates?

3. CAUTION: Statistics may NOT tell us if it is:

• Nosocomical

• A marker

• A causal agent

• The Total Force Plus* health status affects:– Force mission accomplishment– Force readiness and deployability– Force manpower levels– Recruiting– Costs

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* Total Force Plus = AC-RC Service members, recruits/cadets, spouses, children, and retirees/vets.

Total Force Plus Life-Cycle Health Readiness System:Impacts

Total Force Plus Life-Cycle Health Readiness System:Impacts

By 2020, 52.5% of recruitable population will be medically disqualified“Impact of Physical, Behavioral, and Moral Disqualification of Prime Market” 2005

• All members affect the Total Force.• Most diseases and conditions are chronic and relatively

invisible in the short-term.

• “Downstream” issues highlight “upstream” issues. • Retiree Cardio Vascular Disease (CVD) may reflect years of high LDL

cholesterol.

• Child lead levels may reflect service member range safety issues.

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Total Force Plus Life-Cycle Health Readiness System:Why Total Force Plus?

Total Force Plus Life-Cycle Health Readiness System:Why Total Force Plus?

* Total Force Plus = AC-RC Service members, recruits/cadets, spouses, children, and retirees/vets.

• 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.

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Total Force Plus Life-Cycle Health Readiness System:Why Do We Need a Comprehensive Life Cycle System? *

Total Force Plus Life-Cycle Health Readiness System:Why Do We Need a Comprehensive Life Cycle System? *

* See references in Notes

VA 2010 budget request is nearly $113 billion

“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.”

* Estimate based on 2005 Camber Prime Market Study; 2005 DOD QMA Study; 2005 Woods & Poole (2006 projections)

0

6

12

18

24

30

36

Potential Market Qualified Market Prime Market

Mill

ion

s

Incarcerated 0.6

Disqualified 13.9• Medical• Mental• Moral

In-Military 1.1

HSDG IIIB 1.9

HSDG Female I-IIIA3.0

30.8 M

2.2 M

14 M

HSDG Male I-IIIA 3.4 HSDG Male I-IIIA 3.4 HSDG Male I-IIIA 2.2

HSDG < CAT IIIB 2.6

17-24 YO YouthPopulation (M/F)

Total Market minus- Disqualified

Potential Market minus - Cat IV- Non-HSDG

Qualified Market minus - IIIB - I-IIIA Females - No Waivers (1.2 M)

Youth Market

8.3 M

10.7

6.1

5.2

8.8

Non-HSDG 3.1

HSDG Female I-IIIA3.0

HSDG IIIB 1.9

Recruiters must focus on finding the 7.1% (Prime Market)

Numbers BEFOREPropensity is considered

Less than 3 of 10 (17-24 y/o) are fully qualified to serveLess than 3 of 10 (17-24 y/o) are fully qualified to serve

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% 17-20 y/o Who Do Not Meet Army Accession Weight Standards

Source: Nolte et al, “U.S. Military Weight Standards: What Percentage of U.S. Adults Meet the Current Standards?” The American Journal of Medicine, Vol 113, Oct 15, 2002

ObesityObesity

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% 17-20 y/o Who Will Not Meet Army Accession Weight Standards in 2015

Projection based on 35% increase predicted by bariatric experts.

ObesityObesity

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Osteopenia Osteopenia

Source: Dr. Rivero study at Great Lakes Naval Training Center (2001-2002).

• High rates of osteopenia in stress fracture cases.• Women have higher rates of osteopenia and multiple stress fractures.

12/23/09

Note:• PT studies may have results that vary by gender.• Differing osteopenia rates may partially explain that.

Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army Recruits

Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army Recruits

1012/23/09

• 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 website (www.NOF.org) and atwww.shef.ac.uk/FRAX (note criticisms of FRAX)

• Monitoring systems

• Training/Education

• Delivery Systems

• Supply Chain Control

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Total Force Plus Life-Cycle Health Readiness System:Program Structure


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Medical Nutrition Fitness Resilience

Concept

Monitoring

Training/Education

Delivery

Supply Chain

One Team; One Fight

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Total Force Plus Life-Cycle Health Readiness System:Medical



Concept

Integrated Medicine* approach-Improved Stds of Care-Improved Clinical Practice Guidelines-Team-based rehabilitation doctrine

Monitoring• Comprehensive Blood Chemistry Plus** at defined life cycle points.• Injury/disease database (AHLTA Plus) ICW VA & Tricare

Training/Education

• NCOES/WOES/OES (ACCP) (Spouse /family orientation) (DOD Schools/ local HS with mil pop)• Embedded training (posters, Jody calls, etc.)• Diagnosis-based prescriptive (link to Ed Svcs)

Delivery

• Combat-model fix forward treatment (see USMC SMIP ATC)• Enhanced Specialty/MOS/ASI skills• Enhanced MWR staff skills and programs• Enhanced Ed Svc skills and programs

Supply Chain

• Joint programs with CDC• Mixed DODMERB-MEPCOM entry screening model• Recruiting/IET based ‘get ready’ programs

*Health-focused medicine that treats the whole person (body, mind, and spirit), examining symptoms and causes.Ex. 1: Treating a stress fracture with casting and reduced activity and looking at bone health, nutritional deficiencies, diet, and exercise regimens. ** TBD

"The problem with sudden cardiac death is that, of all the people that have heart disease ... half of the time the first symptom is a heart attack," said Dr. Stephen Kopecky, professor of medicine and a cardiologist at the Mayo Clinic in Rochester, Minn. "And half of that half will [die] within an hour."

"The problem with sudden cardiac death is that, of all the people that have heart disease ... half of the time the first symptom is a heart attack," said Dr. Stephen Kopecky, professor of medicine and a cardiologist at the Mayo Clinic in Rochester, Minn. "And half of that half will [die] within an hour."

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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 officer to keep men healthy than it is for a physician to cure them”.

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 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,

walking

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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

Femoral Neck FractureFemoral Neck Fracture

1. Small numbers, but high costs.2. No visibility at DA level.3. 100% Medical Board.4. Lifetime of treatment.1/26/10

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• 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)

• 3 trainers for Parris Island (GIT)/1 ATC for San Diego. • 3 Athletic Training Room (ATRs) for Parris Island

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RESULTS+ Increased Paris Island grad rate (female 68.3% to

74.7%)+ 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.

Fix Forward: USMC SMIP Athletic Trainer InitiativeFix Forward: USMC SMIP Athletic Trainer Initiative

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Prehabilitation

1. Females are at risk for knee injuries

2. Balancing quad-ham muscles reduces knee injuries by 80%.

Pre-training Post-training

1/26/10SportsmetricsTM: the Key to Prevention of Serious Knee Ligament Injuries in Female Athletes, Catherine Walsh, M.S., Women’s Program Manager Cincinnati Sportsmedicine Research and Education Foundation

UntrainedFemales

UntrainedFemales

TrainedFemalesTrainedFemales

MalesMales

Injury Incidence/1,000 PlayerExposures

Injury Incidence/1,000 PlayerExposures

*p< .05*p< .05

Results: All Sports; All Knee Injuries per 1,000 Athlete Exposures

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What Might It Look Like?


What Might It Look Like?

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Total Force Plus Life-Cycle Health Readiness System:Nutrition

Total Force Plus Life-Cycle Health Readiness System:Nutrition

Medical

Nutrition Fitness Resilience

Concept Evidence-based nutrition/supplementation focused on military environment, gender, and tissue monitoring.

Monitoring Comprehensive Blood Chemistry Plus* and relevant test sampling*

Training/Education

• NCOES/WOES/OES (ACCP) (Spouse /family orientation) (DOD Schools/ local HS with mil pop)

• Embedded training (posters, Jody calls, etc.)• Diagnosis-based prescriptive (link to Ed Svcs)• Cooking classes in AAFES/Commissary/MWR

Delivery

• Evidence-based menu/recipes optimized for military environment• Timely access to meals within training OPTEMPO• Meal/snack frequency based on tissue needs• Warrior Bar, Warrior Pak, Warrior Drink R&D concepts• AAFES, MWR, and Commissary participation

Supply Chain

• Enhanced food/supplement inspection and sanitation counter-measures• Healthy food standards (e.g. salad-bar plus beef)• Food production guidelines and inspections (management-intensive grazing)

* TBD

• 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 20

Army BCT Female NutritionArmy BCT Female Nutrition

Naval Female Recruits Calcium and Vitamin D StudyNaval 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 Research1/26/10

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Vitamin D Deficiency/Insufficiency Vitamin D Deficiency/Insufficiency • Military population levels unknown (small USCG study = 60% <30 ng/ml).• Endpoint decision drives numbers (variation by race and latitude).• Militarily significant outcomes (AF Flu Outbreak cost $7M).

Anti-Inflammatory Diet

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Total Force Plus Life-Cycle Health Readiness System:Fitness


Concept Functional/skill and team-based fitness within a quarterly periodization cycle.

Monitoring• Annual with local quarterly periods.• Web-based PT & periodization designer & record system.

Training/Education

• Comprehensive injury prevention program (see Notes).• Fitness ASI.• Expanded Fitness School (includes injury prevention and rehab, nutrition, resilience, etc.).• Enhanced MWR staff skills.• Spouse /family orientation.24

Delivery

• Unit-based. Multiple program choices. Combat parcourse. Prehabilitation exercises.• MWR programs ICW PT school & medical (safe lifting posters; muscle balance guidelines, etc.).• National gym contract for geographically separate Ss (e.g. USCG).• DOD Schools/ local HS with mil pop.• Portable gym equipment (e.g. Exergenie) and/or gyms (see CONEX-based Army BU slide ) (ICW AAFES/MWR).

Supply Chain

• Incentivize Troops-To-Teachers to support HS PT.• Army ‘theme’ (e.g. America Strong) (e.g. USMC Toys for Tots).• Expand JROTC.

Pre-BCT Training ProgramsPrograms are Effective

1. BLUF: The FTU PCU lowers overall discharge attrition by 500-800+ Soldiers (0.4-0.8+%), as well as lowers course attrition and injury rates.

2. 4%-7% of men and 10%-24% of women fail the RECBN 1-1-1 assessment historically. 50-75% of the PCU at GIT sites will be female.

3. PCU Results:

a. Lower course attrition: In the “1-1-1 Fail No PCU” group, men are 2.5 times and women are 1.5 times more likely to attrit from BCT.

b. Lower discharge attrition: In the “1-1-1 Fail No PCU” group, men are 3.0 times and women are 1.9 times more likely to be discharged from BCT.

c. Lower injury rates.

d. The USMA experimental PCU-X vice the traditional PCU improved female outcomes, but male outcomes were worse (but still better than no PCU). Recommendation is that USAPFS design a new PCU PT POI.

e. Option: a 12 week BCT PCU company to maximize program flexibility, maintain bonding, provide non-PT training, get resourced, etc.

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Control Group

Standardized PT Program

Week 1 Week 3 Week 5 Week 9

Time (in weeks)

Injury Rates

33% decrease

Injury Control

USAPFS Standardized PT ProgramUSAPFS Standardized PT Program

Good PT design maintains/exceeds standards

and lowers injury rates

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• 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

AMEDDC&SOperation Aegis

Injury Control

If implemented at all IET/AIT sites: $9M/yr & 1.5M limited duty days/yr Potential

Savings1/26/10

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0%

20%

40%

60%

80%

100%

1994 1995 1996 1997 1998 1999

Uninjured

1,834 Injuries Prevented

Injured

Results for Army Basic Training: Injury

0%

20%

40%

60%

80%

100%

1994 1995 1996 1997 1998 1999

Training Successes

Discharged

1,260 Discharges Prevented

Results for Army Basic Training: Attrition

Defence Injury Prevention Program (DIPP)Australian Department Of DefenceAustralian Department Of Defence

Defence Injury Prevention Program (DIPP)Australian Department Of DefenceAustralian Department Of Defence

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.

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Total Force Plus Life-Cycle Health Readiness System:Resilience

Total Force Plus Life-Cycle Health Readiness System:Resilience

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Concept• Positive life skills to adapt to stress and hardships.• Integrated resilience, Battlemind, and CONOPS sequential

and progressive by level.

MonitoringDiagnostic test battery based training (e.g. Success Profiler) (individual as appropriate).

Training/Education

• Enhanced Beh Science Specialist MOS training

Delivery

• Pre-enlistment R&D (train in/screen out)• Pre-BCT ‘get ready’ training• Chaplain combat-style resilience training in IET• Embedded training (posters, Jody calls, etc.)• NCOES/WOES/OES• Spouse /family orientation

Supply Chain

• Incentivize Troops-To-Teachers to support HS Wellness program.

• Army ‘theme’ (e.g. America Strong) (e.g. USMC Toys for Tots)

• Expand JROTC.

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• Our current cohorts of DoD recruits arrive at IET with significant developmental experiences:

– 40% come from ‘non-traditional’ homes without two consistent parenting figures*

– 19% of HS students had seriously considered attempting suicide during a 12 month period**

– 8% of HS students reported making a suicide attempt in the preceding 12 month period**

• Our current cohorts of DoD recruits arrive at IET with significant developmental experiences:

– 40% come from ‘non-traditional’ homes without two consistent parenting figures*

– 19% of HS students had seriously considered attempting suicide during a 12 month period**

– 8% of HS students reported making a suicide attempt in the preceding 12 month period**

Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research

Civilian Population

31*Wolfe, J. (1996-2000). Adaptation to First-Term Enlistment Among Women in the Marine Corps. DAMD 17-95-1-5047.

1. More ACE factors increase risk.2. Associated high-risk behaviors (sex,

drugs, smoking,, etc.)3. Associated impacts (health, disease, poor

job performance, depression, etc.).4. Diminished brain development.5. Treatable.

Adverse Childhood Experiences (ACE)Adverse Childhood Experiences (ACE)

USMC

SampleNational Samples

Men Women Men Women

Child physical

26.7 38.3 3.2 4.8

Child sexual

14.7 51.0* 3-16 12-27

Table shows only 2 factors.Having 3+ factors does increase risk somewhat, but

does not automatically mean all are ruined.

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Alcohol abuse 23.5% 33.0%Mental illness 17.5% 21.1%Battered mother 11.9% 6.8%

Exposures Civilian Army Infantry

Childhood Abuse Civilian Army Infantry Psychological 10.0% 20.0% Physical 4.9% 13.8% Sexual 19.3% 3.8%

Adverse Childhood Experiences (ACEs) are Common in Civilian and Military Populations

•Data from civilian population from CDC ACE study (n=9,508). Infantry population based on AC combat unit (n=4,602)(WRAIR OIF /OEF behavioral health research project). Note: Data does not adjust for differences in population demographics. Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research

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The Dark Side

AttitudesAttitudes

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.

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no TLAC training and no OIF/OEF experience

no TLAC training and OIF/OEF experience

TLAC training (with classroom instructor) but no OIF/OEF experience

Training critical thinking works!Source: ARI

Adaptive ThinkingAdaptive Thinking

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Expert Patterns of Battlefield Thinking

Keep a focus on mission accomplishment and higher commander's intent.

Model a thinking enemy. Consider effects of terrain. Use all elements/systems

available. Include considerations of timing. Exhibit visualizations that are

dynamic and proactive. Consider contingencies and

remain flexible. Consider how your fight fits into

the bigger picture from friendly and enemy perspectives.

Positive LeadershipPositive Leadership

USMA Peak Performance Model:

Training the Warrior Pentathlete

PeakPerformance

Attention Control

Cognitive Foundations

Goal

SettingVisualization =

Stress & Energy Mgmt

ARI – Infantry Forces Research Unit United States Olympic Committee 1998

The most critical training that prepared Soldiers for efficient and effective task accomplishment under life-threatening, fast-paced, and stressful conditions are:

• Time management• Command of the basics• skill mastery• Combat focus• Visualization• Repetition, and • Use of job aids

Human performance at elite levels is heavily dependent upon intangible, mental factors, i.e.

• Confidence despite setbacks, • Concentration amidst distractions, • Composure during times of stress.

Physical

Technical

Tactical

Mental

Emotional

Self RegulatingInstinctiveAdaptiveAgileMental Effort

WarriorMindset

Build confidenceControl attentionRecover energy‘See’ the battlefield

Combat PT8-Step AARRote Repetition

Self criticalAnalyticalJudgmentalPhysical effort

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• Force mission accomplished• Force ready and deployable• Force manpower levels met• Costs equal or lower

Total Force Plus Life-Cycle Health Readiness System:Outcomes

Total Force Plus Life-Cycle Health Readiness System:Outcomes

One Team; One Fight

Total force health sys 26 jan 10

Health & Medicine

Transcript of Total force health sys 26 jan 10