APRIL 13, 2021 – One of the challenges all Army leaders face is balancing readiness and training needs while preventing or reducing Soldier injuries. The Army Public Health Center recently released a guide for leaders offering specific recommendations and strategies to help leaders achieve the goal of injury reduction.
“What Leaders Can Do to Increase Readiness” (referred to here as “the leader guide”) contains eight recommendations targeting the top causes of Soldier medical non-readiness. It is intended to promote and facilitate leadership engagement in these strategies.
Former Sergeant Major of the Army Raymond Chandler said the key to resiliency is engaged leadership at the first-line supervisor level. Engaged leaders are able to identify issues with their Soldiers’ physical and mental well-being. Many times leaders are able to recognize these issues before the Soldiers themselves. This allows leaders to help guide Soldiers to the appropriate resource to address their needs.
Sergeant Major of the Army Michael Grinston echoed this sentiment at the October 2020 gathering of the Association of the United States Army.
“Our focus is on leadership and building cohesive teams,” said Grinston. “‘This Is My Squad’ is about creating fit, disciplined and well-trained teams. It is about listening to and understanding our people. It’s about showing compassion and empathy for all.
Most importantly, it is about junior leaders creating positive energy, making decisions and taking action within their squads to support teammates.”
The importance of good communication is conveyed by the Army Leadership Model of Be, Know, Do. According to FM 6-22, the Army field manual on leader development, this model aligns the desired outcome of leader development activities and personnel practices to a common set of characteristics valued throughout the Army. Attributes are the desired internal characteristics of a leader – what the Army wants leaders to BE and KNOW. Competencies are skills and learnable behaviors the Army expects leaders to acquire, demonstrate, and continue to enhance – what the Army wants leaders to DO.
“Effective leaders ensure Soldiers have access to the services they need,” said Dr. Abby Bickford, an Oak Ridge Institute for Science and Education fellow supporting APHC curriculum development in suicide prevention. “Unit commanders can influence access through their unit’s noncommissioned officers. Studies show that NCOs daily and direct engagement with the unit can significantly influence Soldier behavior. NCOs that advocate for help-seeking have been associated with higher levels of unit physical and mental well-being.”
The leader guide is supported and informed by the APHC Injury Prevention Branch, which routinely evaluates the causes of Soldiers’ injuries using multiple data sources. Running is consistently found to be, by far, the leading cause of active-duty Soldier injuries. The leader guide clearly presents these findings.
“Most recently we have evaluated Soldiers’ medical profile data,” said Dr. Bruce Jones, a retired Army colonel and APHC senior science advisor on injury. “The leading causes of injuries among Soldiers who were given medical profiles are running, Military Occupational Specialty work-related tasks, falls/slips and trips, road marching and sports.”
Jones states that injuries are the leading health problem of the Army, accounting for more than 2 million clinic visits per year. The second leading reason for clinic visits is behavioral health, at about 1 million visits per year. Of the 10 million limited duty days prescribed for Soldiers each year, 60 percent are for musculoskeletal or MSK injuries. Behavioral health conditions account for 10 percent of limited duty days, followed by neurological conditions at 2 percent. Jones emphasized that MSK overuse injuries can frequently be prevented through modifications of unit and personal training regimens.
Dr. Anna Renner-Schuh, an APHC public health and safety analyst, points out that other injury data sources echo these findings.
“For example, in a recent study of a large infantry division, the leading self-reported activities associated with injuries were running, lifting or moving heavy objects, walking, hiking, or road marching, sports and recreation, and other non-running physical training,” said Renner-Schuh.
As illustrated in the leader guide, Soldiers spend an average of 37 days on limited duty per injury, and 71 percent of these injuries are micro-traumatic MSK overuse injuries, which are generally preventable.
“Overtraining is the presumed cause of overuse injuries,” said Jones. “The signs of overtraining in individuals are fatigue, decreased physical performance (such as slower run times) and injuries.”
Jones explained that commanders have data at their disposal to monitor these factors, including unit training metrics, unit fitness test scores and unit profiles.
“If a unit is running or marching more and run times are getting slower and injury rates are going up, those are cardinal signs of overtraining,” said Jones.
However, the amount of running that leads to injury is often unique for each individual. Jones explained that although standardized training requirements are needed to ensure fitness and readiness, the amount of running that contributes to overuse injury is different depending on the type of unit, such as infantry, armor, Special Forces, or medical.
“But regardless of the unit, higher levels of physical fitness, in particular aerobic fitness, have been shown to be protective against injuries in the past,” said Jones. “That may change with the transition to the Army Combat Fitness Test, which places more emphasis on strength and power.”
Recent past injuries have been shown to predispose Soldiers and athletes to higher risks of future injuries, said Jones.
“Given that over 50 percent of Soldiers are injured annually, a Soldier who has been in the Army more than a couple of years will more than likely have suffered an injury sometime in their career,” said Jones. “So, what is important is to make sure each injury has adequate time to heal.”
The leader guide presents a number of approaches that can be employed to help prevent injuries and promote readiness.
Army Wellness Centers are installation resources recommended by the leader guide. Using the AWCs is a way for engaged leaders to provide support for Soldiers struggling with maintaining fitness standards, or who need help with issues such as nutrition and stress.
“An engaged leader understands the Army Wellness Center mission and advocates for the program’s capability to improve the readiness of our Total Army and reduce the overall risk of injury of our active-duty Soldiers,” said Joanna Ward-Brown, project officer for AWC operations. “An engaged leader also encourages and allows Soldiers the opportunity within their duty day to utilize AWC services.”
AWCs offer a gold standard body composition assessment via the BodPod that provides an individual with an accurate, baseline measurement of their total body fat, Ward-Brown added. From there, Soldiers can receive ongoing health coaching and individualized exercise prescriptions that target the Soldier’s specific needs, increase their healthy behaviors and improve their overall body composition.
Army Wellness Centers also provide a stress management class that educates Soldiers on the causes and effects of stress, and introduces techniques that individuals can practice to mitigate stress, said Ward-Brown. AWCs also provide Individualized Stress Management Technique sessions in which a Soldier can practice techniques one-on-one with an AWC Health Educator. A software application is used during the session which provides direct feedback on the technique’s effect on the individual’s physical and mental state.
Another resource for leaders is their local behavioral health provider. Army behavioral health providers give Soldiers and leaders numerous resources to improve resilience and manage stress, said Army Lt. Col. Jeffrey Bass, a psychologist with APHC’s Behavioral and Social Health Outcomes Program. One example is a command consultation on effective unit and individual health and welfare. Chaplains and military and family life counselors also provide support.
Bass said behavioral health specialists can provide basic unit training on Suicide Prevention/Management, Master Resiliency Training and the Performance Triad (P3), which emphasizes the importance of sleep, activity and nutrition, or SAN.
Though specific scientific studies have not yet shown that improving all three SAN behaviors together will further decrease injuries, it is a commonsense approach to improving overall health and resiliency against illness and injury, said Bass. Some evidence suggests improving SAN behaviors can enhance cognitive acuity: attention, concentration, decision-making and problem-solving. This may help prevent injury by assisting Soldiers in making improved health and fitness choices, increasing compliance with safety protocols, following smart training principles, increasing awareness of injury risk factors, and adhering to rehabilitation guidance.
The Performance Triad is the Army program that promotes the benefits of sleep, activity and nutrition. Maj. Tim Benedict, a physical therapist working on APHC’s injury prevention team, also sees the Performance Triad as a way to help manage stress.
“For me, this goes back to the issue of stress,” said Benedict. “When you are under high levels of stress, you are just trying to survive, not thrive. When you look at your life holistically and try to manage stress, then exercise, sleep and nutrition are key ways to decrease stress.”
The leader guide says it’s important Soldiers feel confident about returning to duty, because lack of resilience or confidence impact a Soldier’s desire to return. It recommends Soldiers complete a full course of rehabilitation with physical therapy after an MSK injury, especially Soldiers who do not yet feel confident in their ability to perform physical military tasks.
A key question, according to Jones, is whether physical training, psychological techniques, or a combination of these two strategies is more effective at increasing most Soldiers’ abilities to perform physical tasks and prevent injuries.
The leader guide recommends that Soldiers consult with their primary care physician or behavioral health specialist if they have concerns about their sleep. Leaders can also work with their local behavioral health providers on implementing resilience and stress management programs.
Army behavioral health providers can assist Soldiers in improving their sleep by accurately assessing daily sleep schedules via “sleep logs” and identifying modifiable risk and protective factors, and advising on clinical and behavior techniques to improve sleep problems, said Bass.
“They can also train Soldiers on common sleep hygiene protocols during unit Sergeant’s Training Time activities,” said Bass. “The ultimate goal would be to have squad leaders and/or platoon leadership consistently espouse the value of improved sleep and offer practical strategies for improved sleep at various unit encounters, including morning physical readiness training, end-of-day unit huddles and weekly safety briefs.”
Using the recommendations in the leader guide, engaged leaders, especially first-line supervisors, can apply many means of improving Soldier readiness. Army Wellness Centers, behavioral health providers, and the Performance Triad integrate to form a robust solution to the most frequent causes of medical non-readiness.
The guide can be downloaded and print copies ordered at https://ephc.amedd.army.mil/HIPECatalog/viewItem.aspx?id=1846.
The Army Public Health Center enhances Army readiness by identifying and assessing current and emerging health threats, developing and communicating public health solutions, and assuring the quality and effectiveness of the Army’s Public Health Enterprise.
Story by Douglas Holl
Army Public Health Center