Medical Attrition from Commanders Training in the Israeli Defense Forces (IDF): A Cross-sectional Study on 23,841 Soldiers

Medical Attrition from Commanders Training in the Israeli Defense Forces (IDF): A Cross-sectional... Abstract Introduction Attrition from training is associated with substantial financial and personnel loss. There is a plethora of medical literature and research of attrition rates related to initial/phase 1 training (basic combat training); however, the analysis of second phase training (commanders training, consisting of schools that qualify junior commanders and officers for infantry and non-infantry combat units) is limited. The purpose of this study is to perform a comprehensive survey regarding to medical attrition from commanders training in the IDF (Israeli Defense Forces) in order to present the commanders of the IDF a detailed situation report that will serve as an evidence-based platform for future policy planning and implementation. Methods A cross-sectional study including all soldiers (23,841) who participated in commanders training in the IDF in the period of 2012–2015 was performed. Soldiers for whom the attrition reason (medical or not medical) was missing were excluded from this study. Data were collected from the adjutancy-computerized system as well as the IDF’s computerized medical consultation records package (CPR). Descriptive statistics were performed using mean, standard deviation, and median in order to express results. For the determination of statistical significance, chi-square test, Student’s t-test, and Poisson regression models were used. Results Out of 23,841 soldiers that participated in this study, 75% (17,802) were males and 25% (6,039) were females. The overall attrition rate was 0.7% (164). The attrition rate for males was 0.86% (148 out of 17,082 males) and 0.26% (16 out of 6,039 females) for females. After adjusting for training unit, age, and BMI, the risk for attrition was 1.6 (160%) times higher for males as compared with females, and this result was statistically significant (IRR = 1.6, p = 0.01, CI 1.1, 2.2). The re-injury rate was 41% (68 out of 164 soldiers). The three most frequent diagnoses for attrition were orthopedics (66%), general surgery diagnoses (12%), and diagnoses related to internal medicine (11%). Out of 107 soldiers that attired due to orthopedic reasons, 36 (34%) suffered from calf and ankle injuries, 22 (21%) attired due to diagnoses related to the lower back, and 22 (21%) attired due to diagnoses related to the knee region. The highest attrition rate was encountered in the school for infantry junior command (2.2%) and the lowest rate was encountered in the officer training school for non-infantry units (0.11%). After adjusting for age and BMI, the risk for ankle injury was 2.55 (255%) times higher for soldiers in the school for infantry junior command as compared with soldiers in the officer school for infantry units (IRR = 2.55 p = 0.017, CI 1.18, 5.47). Conclusion The attrition rate from commanders training in the IDF is low, and at this point, however, due to lack of uniform criteria for attrition, it cannot serve as an objective measure. We suggest measuring and discussing overuse injury rates (which is the most frequent cause of attrition), instead. Based on our results, we recommend an implementation of a better medical screening policy in order to reduce the re-injury rates during commanders training. INTRODUCTION In the IDF (Israeli Defense Forces), medical attrition is defined as training incompletion due to medical reasons (organic or mental).1 Attrition from training is associated with substantial financial and personnel loss.2,3 The rate of attrition from basic combat training in the IDF is 3.44%, of which, 64% are due to orthopedic and mental diagnoses (43% and 21%, respectively).1 Out of 43% of attrition due to orthopedic diagnoses, 90% are due to overuse injuries,3 and as in other armies, these injuries are the leading cause for medical consultations (more than 50% of all medical consultations).1,4,5 Overuse injuries have the malicious potential of causing severe damage on the personal level in terms of daily function and quality of life. On the day-to-day unit, daily activity, and training cycle, these injuries are the leading cause for lost training days, have detrimental effects in terms of operational effectiveness, and pose a serious economic burden (approximately $2 billion per year in the US Army).2,6–7 Previous research in the IDF found no differences in attrition rates between infantry and non-infantry combat training units (RR = 0.95, p = 0.51).1 There is a plethora of medical literature and research of attrition rates related to initial/phase 1 training (basic combat training); however, the analysis of second phase training (commanders training, consisting of schools that qualify junior commanders and officers for infantry and non-infantry combat units) is limited. A literature review revealed one study on 321 soldiers from the Norwegian army, which demonstrated similar rates of overuse injuries for commanders training as compared with basic combat training.8 The overall overuse injury rate on this study was 25%, and the majority (85%) were in the lower back and the lower limb regions. Similar results were obtained in studies performed in the US Army.9–12 Purpose To perform a pilot survey analysis of medical attrition rates from commanders training in the IDF. To initiate evidence-based strategic policy and intervention programs. METHODS Study Design and IRB (Institutional Review Board) Approval A cross-sectional study was conducted. This study was approved by the IDF’s IRB, approval number: 1203–2012. Population All soldiers participating in commanders training between 2012 and 2015 (total of 23,841 soldiers) in the four commanders training units of the IDF: The school for infantry junior command – qualifying junior commanders to all IDF’s infantry combat units: total number of soldiers: 4,988, training period: 4 mo. The school for non-infantry junior command – qualifying junior commanders to all IDF’s non-infantry combat units: total number of soldiers: 5,790, training period 3 mo. The officer training school for infantry units – qualifying officers for all of the IDF’s infantry combat units: total number of soldiers: 4,741, training period 8 mo. The officer training school for non-infantry units – qualifying officers for all of the IDF’s non-infantry combat units: total number of soldiers: 8,322, training period 5 mo. All soldiers participating in commanders training were found medically fit to serve in combat units according to the medical profile score of the IDF3 and successfully completed basic combat training. Before admission to one of the commander schools, all participants underwent a medical examination performed by the school’s physician in order to establish medical fitness. Soldiers with acute injuries, with physical restrictions due to medical reasons, and soldiers under investigation for medical condition that may influence their ability to fully adhere and complete the training program were not admitted to training. Exclusion Criteria The exclusion criteria include soldiers for whom the attrition reason (medical or not medical) was missing. Data Collection Data were collected from the adjutancy-computerized system as well as the IDF’s computerized medical consultation records package (CPR). We used the adjutancy-computerized system in order to identify all discharged soldiers. After identifying those soldiers, we used the IDF’s computerized medical consultation records package (CPR) to identify the medical reason responsible for the drop out. The following variables were collected: training unit, age, sex, weight, height, BMI, date of training start, date of injury, place of injury (in unit/out of unit), type of medical attrition (organic/mental), body system, and injury site (only for orthopedic/overuse injuries cause of attrition). Orthopedic/overuse injury diagnosis was defined as any medical diagnosis (disease, overuse injury, or trauma) related to the musculoskeletal system. Data Analysis STATA (version 14.0, College Station, TX, USA) and SPSS version 23.0 were used for statistical analysis. Descriptive statistics were performed using means, standard deviations, and medians in order to express results. For the statistical significance of the comparison of two dichotomous variables, the chi-square test was used. For the statistical significance of the comparison of quantitative variables divided into two categories, Student’s t-test was used. Although this is primarily a descriptive study, some associations between exposure and outcome variables were examined. For obtaining these associations after adjusting for potential confounders and the differences in training periods between training groups, Poisson regression models were used expressing the results in IRR (incidence rate ratio). Results In this study, 23,841 soldiers that participated in one of the commander’s training school programs were included: 17,802 (75%) men and 6,039 (25%) women. For detailed distribution of total number of soldiers, injured soldiers, discharged soldiers, and attrition/injured soldiers ratio by training unit, see Table I. No correlation was found between attrition or injury rates and the duration of the training. The lowest attrition rate was observed in the non-infantry officer’s schools with a training period of 5 mo (0.12%), whereas the higher attrition rate was encountered in the infantry junior command school with a training period of 4 mo (1.8%). The highest rate of injuries was observed in the non-infantry officer’s school, 27.6%, with a training period of 5 mo, whereas the lowest injury rate was observed in the infantry junior command, 11.4% with a training period of 4 mo. The rate of injuries in the infantry officer’s school with the longest training period of 8 mo was 22.2%, lower than the injury rate in the non-infantry officer’s school, 27.6%. Table I. Distribution of Total Number of Soldiers, Injured Soldiers, Discharged Soldiers and Attrition/Injured Soldiers Ratio by Training Unit.   SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230      SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230    SIJC, School for Infantry Junior Command; SNIJC, School for Non-infantry Junior Command; OTSIU, Officer Training School for Infantry Units; OTSNIU, Officer Training School for Non-infantry Units. Table I. Distribution of Total Number of Soldiers, Injured Soldiers, Discharged Soldiers and Attrition/Injured Soldiers Ratio by Training Unit.   SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230      SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230    SIJC, School for Infantry Junior Command; SNIJC, School for Non-infantry Junior Command; OTSIU, Officer Training School for Infantry Units; OTSNIU, Officer Training School for Non-infantry Units. For detailed description of sample sizes and injury and attrition rates, see Figure 1. Figure 1. View largeDownload slide Detailed description of sample sizes and injury and attrition rates. Figure 1. View largeDownload slide Detailed description of sample sizes and injury and attrition rates. For details regarding height, weight, and BMI distributed by training completion status, see Table II. Table II. Weight, Height, and BMI Distributed by Training Completion Status.   Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058    Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058  Table II. Weight, Height, and BMI Distributed by Training Completion Status.   Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058    Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058  The 164 soldiers discharged due to medical reasons were categorized by the medical discipline that the main diagnosis for attrition was established and treated by. Out of the 164 discharged soldiers, 107 (66%) were discharged due to orthopedic/overuse injuries diagnosis, 19 (12%) discharged due to diagnoses related to the general surgery discipline, and 11 (7%) due to diagnoses related to the internal medicine discipline. The frequency of attrition by medical specialty is detailed in Figure 2. Figure 2. View largeDownload slide Detailed frequency of attrition by medical specialty among 164 discharged soldiers. Figure 2. View largeDownload slide Detailed frequency of attrition by medical specialty among 164 discharged soldiers. Out of 107 soldiers that were discharged due to orthopedic/overuse injury diagnoses, 36 (34%) suffered from calf and ankle injuries, 22 (21%) were discharged due to diagnoses related to the lower back, and 22 (21%) were discharged due to diagnoses related to the knee region. Out of 36 soldier discharged due to calf and ankle diagnoses, 31 (88%) suffered from ankle sprains and stress fractures of the distal tibia. Out of 22 soldiers discharged due to diagnoses related to the knee region, 17 (87%) suffered from ACL injury or meniscal tear and were treated by surgery. For detailed breakdown of orthopedic/overuse injury attrition by body site, see Figure 3. Figure 3. View largeDownload slide Frequency of orthopedic/overuse injuries attrition by body site. Figure 3. View largeDownload slide Frequency of orthopedic/overuse injuries attrition by body site. Out of 164 discharged soldiers, 68 (41%) were discharged due to aggravation of a well-known and documented medical diagnoses diagnosed before the beginning of training. After adjusting for age and BMI, the risk for ankle injury was 2.55 (255%) times higher for soldiers in the school for infantry junior command as compared with soldiers in the officer’s school for infantry units (IRR = 2.55, p = 0.017, 95% CI 1.18, 5.47). Training unit did not result as a risk factor for lower back and knee injuries. For detailed Poisson regression model results for the risk for ankle injuries, see Table III. Table III. Poisson Regression Model Results for the Risk of Ankle Injuries. Results Are Adjusted for Age and BMI.   IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)    IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)  Table III. Poisson Regression Model Results for the Risk of Ankle Injuries. Results Are Adjusted for Age and BMI.   IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)    IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)  The attrition rate for men was 0.86% (148 out of 17,082 men) and 0.26% (16 out of 6,039 women) for women. After adjusting for unit, age, and BMI, the risk for attrition was 1.6 times (160%) higher for men as compared with women (IRR = 1.6, p < 0.001, 95% CI 1.1, 4.2). Discussion The Salient Findings of this Study There are different criteria for attrition between units; hence, attrition rates cannot serve as an objective uniform measure and cannot be compared between units. There is no correlation between injury and attrition rates among all units. There is no correlation between training’s duration and injury and attrition rates. Most of attrition (66%) is due to overuse injuries. Most injuries occur in the lower back, knee, and calf and ankle regions. There are high re-injury rates (41%). There are higher rates of injuries in the infantry officer’s school as compared with the infantry commander’s and basic combat trainings. Men are at higher risk for injury than women. In our opinion, these findings are significant for further decision-making and policy planning and implementation. Each of these findings will be further discussed in details. Attrition Rates Although statistically significant, the differences in height and weight between the attrition group and the group that finished training were minor and practically clinically insignificant (2 cm difference in height and 1.5 kg in weight). We did not find any differences between the two groups regarding other demographic and anthropometric data. The overall rate of attrition from commanders training according to this study is 0.7%. We consider this rate to be low absolutely and relative to attrition rates in basic combat training (2.5%).1 However, as the decision to drop out a soldier is influenced by other considerations rather than the medical condition (such as operational and staffing standards considerations), attrition criteria are not the same for all units. Therefore, we think that attrition rates cannot serve as an objective uniform measure, and attrition rates cannot be compared between units. More than that, as attrition cannot serve as an objective measure, it cannot be discussed without discussing the main cause for medical attrition which is overuse injuries (107 out of 164 soldiers, 66%). Overuse Injury Rates and Comparison to Injury Rates in Basic Combat Training Units The overall injury rate in the IDF’s basic combat training units is approximately 25%, 18% in the infantry basic combat units, and approximately 36% in the non-infantry units.13 As demonstrated in our results, the injury rates in the non-infantry commander’s schools are lower than in the basic combat training of these units (28% in the non-infantry officers’ school and 19% in the non-infantry junior command school). The injury rate in the infantry combat training units is higher than in the infantry commander’s school (18% vs. 11.4%) and lower than in the infantry officer’s school (18% vs. 22.2%). The increase in injury rates in the infantry officer’s school as compared with basic combat and junior commander’s trainings of infantry units is in our opinion worrisome. We expected to find a substantial decrease in injury rates in all second phase of training (commanders schools) as the soldiers selected to this training are usually more experienced with better physical fitness, have higher motivation, and successfully passed the natural selection of the basic combat training. Furthermore, soldiers in the officer’s school are considered to be more responsible, more disciplined, and more aware for injury prevention than soldiers in infantry basic training, and in the infantry junior command, cadets are usually trained by the best physical fitness officers and teams, and the commanders of the officer’s school should be highly aware of the risk of injuries and injury prevention. If we assume that the quality of soldiers and staff is higher in the officer’s schools, the high rate of injuries among cadets in the infantry officer’s school may be explained by other possible reasons as follows: The training program – the bar is set too high – The intensiveness and the physical effort demands of the training program are too high, leading to overtraining and injuries. Over motivation and concealing of information – Due to the fear of not being admitted to the officer’s school, some soldiers are reluctant to report or seek for medical treatment for known injuries or symptoms. However, during the officer’s training, the symptoms and injuries are aggravated and finally reported. Re-injury – as previously mentioned, the re-injury rate in this study was 41%. It might be that previously injured soldiers did not completely heel from their previous injury and were not properly prepared to return to full activity after injury. During the high intensive training in the officer’s school, the vulnerable site of previous injury is exposed to re-injury. Accessibility and availability of medical services – It might be that some injuries were not reported before officer’s school training due to medical service availability and accessibility issues. Our main recommendation regarding the increase in injury rates in the infantry officer’s school as compared with basic combat and junior commander’s trainings of infantry units is an immediate investigation of the reasons for this worrisome increase in injury rates including a comprehensive investigation of the training program. Attrition vs. Injury Rates The highest attrition/overuse injury ratio was observed in the infantry junior command school. These substantial differences in attrition/overuse injury ratio between units may in our opinion serve as a solid evidence to the above statement that attrition cannot serve as an objective measure and cannot be discussed without discussing overuse injuries. Different policies regarding medical attrition may also affect the future risk for injury and the ability to continue and serve in a combat unit. Therefore, we think that a study that examines the rates of injury and discharge from combat units after qualifying a commander’s school is crucial in order to understand the influence of attrition policy on both variables. In this study, we did not find any relation between type of injury and time of discharge (e.g., the time from injury to the decision to discharge). The main reason for this lack of relation is that the decision to discharge is based individually on many cases. For the same injury, there are soldiers that will be discharged and others that will not, depending on many individual or specific factors such as the timing of injury in terms of the training phase, the individual heeling pace, and the amount of lost training days. The latter two are difficult to predict; hence, in some cases, soldiers that were predicted to fully recover and qualify the training will be unexpectedly discharged due to more than expected lost training days. Furthermore, as previously mentioned, the decision of discharge is influenced by other factors rather than pure medical considerations; hence, there is inconsistency regarding discharge policy including discharge timing between units. Duration of Training vs. Attrition and Injury Rates Intuitively, the duration of training should be strongly correlated with both attrition and injury rates. However, the results of this study demonstrate no correlation between the training period and the attrition or overuse injury rates. These surprising results suggest that the period of training plays a secondary role in the risk for injury or attrition. Other factors that may be more correlated with risk for injury and attrition may be related to the quality of training, rather that the training period, such as the physical effort demands, quality and adherence to the training programs by avoiding over or undertraining,4,5,10,14 the quality of the training personnel, and the basic fitness of the trainees. Re-injury Rates The re-injury (repeated injury during commanders training that was well reported and documented before the beginning of commanders training) rate in this study was 41%. This rate in our opinion is high and should be substantially reduced by personal restrictions and training instructions for the pre-injured soldiers, and in unique cases of severe pre-injury, the exclusion of these soldiers from commanders training. In our opinion, according to these findings, a better medical process of screening and selection by the physicians of the commander’s schools should be performed. Basic fitness tests and basic MSK (Musculoskeletal) injury questionnaire may be efficient screening tools that can be used by the screening physician and we recommend the usage of such tools in the admission process of all commanders’ schools. Distribution of Overuse Injuries by Body Site Similar to medical attrition from basic combat training,3 most of the medical attrition in commanders training is due to orthopedic/overuse injury diagnoses (66%) and most of the injuries were in the lower back and lower limb regions. The most frequent body sites for overuse injuries were the calf and ankle (34%) followed by the knee (22%) and the lower back. Approximately 90% of injuries in the calf and ankle regions were ankle sprains and stress fractures of the distal tibia. Approximately 90% of knee injuries were meniscal tears and ACL injuries. These injuries, especially the ACL injury, are considered to be relatively severe injuries, are usually treated by surgery, demonstrate high rates of complications, and are associated with a long period of training loss. Therefore, these injuries will almost always end with discharge and attrition. Based on the above, we think that a special focus and effort should be drawn in order to reduce ankle sprains and stress fractures of the distal tibia mainly due to their high frequency and meniscal tears and ACL injuries mainly due to their severity. Training Unit as a Risk Factor for Ankle Injury We found that soldiers in infantry junior command training have 2.55 higher risk for ankle injury than soldiers in officer’s school for infantry. Explanations for this finding may be: Trainees in officer’s schools are usually more responsible, more disciplined, and more aware for injury prevention. Almost all trainees in officer’s schools usually participate in junior commanders training; hence, the junior commander training serves as a natural screening phase to the officer’s school. Usually, trainees in officer’s schools are trained by the best physical fitness officers and teams and the commanders of the officer’s school are highly aware of the risk of injuries and injury prevention. However, in this context, the overall overuse injury rates are twice as high in the officer’s school as in the junior command. Therefore, it might be that the above explanations play a secondary role in explaining this higher risk and the main factor responsible for this risk is the different components of the training program between the two schools. Nevertheless, in order to establish the exact reasons for the higher risk for ankle injury in the junior commander training as compared with the officer’s school, further investigation by analytic studies is necessary. Attrition Due to Mental Diagnoses The attrition rate due to mental diagnosis was 3%. This number is absolutely and relatively low as compared to the rate in basic combat training (21%). This low rate may be explained by the fact that soldiers selected to the commanders training are more mentally resilient than recruits, and as commander training in the IDF is voluntary, the motivation of these soldiers is usually high, which substantially contributes to the mental resilience. Sex Differences In our study, men have 1.6 times higher risk for injury as compared with women. This finding is surprising as female gender is considered to be one of the major risk factors for injury. Thirty-three percent of all soldiers in the IDF are women; of them, 7% are warriors in combat units. Ten percent of all warriors are women, most of them serving in the field intelligence force and the mixed battalions performing duties of borders keeping. One explanation for the higher risk of injury for men as compared with women may be the fact that only those women with highest levels of motivation and physical fitness will be assigned to command training. Other explanation may be provided by the fact that most women are assigned to the officer’s school for non-infantry units in which the training program and the required physical demands and efforts are much lower than in the infantry commander schools. Nevertheless, as a result of the implementation of the Israeli government’s decision to equally open for men and women all combat duties in the IDF, the number of female warriors is expected to substantially increase and the duties they serve may be much more varied. As a result, much more women are expected to be assigned to the other commander’s schools rather than the non-infantry officer’s school. This may substantially change the risk for women to be injured as compared with men. Study’s Advantages and Limitations The main advantage of this study is the population size, which enables detailed situation report and characterization of the medical attrition from commanders training. However, this study has limitations: It is a descriptive and cross-sectional study; hence, causality between exposures and results could not be properly assessed. There was no blinding, so bias in reporting or data collection cannot be excluded. The risk from incorrect original data entry may be a profound limitation: There is a great variety between physicians and medical personnel regarding to medical recording and diagnoses documentation; hence, there is a lack of uniformity regarding the documentation of medical consultations. This lack of uniformity may reduce the quality of data and create difficulties in data collection and analyze. The time from training beginning to date of attrition/injury was missing in more than 50% of participating soldiers. These missing data did not allow us to use a Cox model, which is the best way to account for the substantial differences in the duration of training between the different schools. We partially overcome this issue using a Poisson model with the duration of training expressed in person months as the offset variable. However, using Poisson models for our data had some disadvantages such as the variable types and overconfidence. Furthermore, these missing data did not allow us to understand if there is a pivotal duration when injury occurs. Lack of quality research in this field to draw upon or compare too. Conclusions and Recommendations The population size of this study enabled us to produce a detailed situation report with several significant findings that can serve as a solid base for policy planning and implementation and further investigation Better specificity of recording and data management are required for better analysis of data in future research. The attrition rate from commanders training in the IDF is relatively low, and at this point, however, the results of this study suggest that attrition cannot serve as an objective measure for the soldier’s health nor for the rates of overuse injuries. Uniform criteria for medical attrition should be formulated by the IDF commanders. Those criteria should be mostly based on medical decisions. A study that examines the rates of injury and discharge from combat units after qualifying a commander’s school should be conducted. A better medical screening policy should be planned and implemented in order to reduce the rates of re-injury during commanders training. Basic fitness tests and basic MSK (musculoskeletal) injury questionnaire should be considered as some of the screening tools. An immediate investigation of the training program in order to verify whether the bar is set to high should be performed in the infantry officer’s school. Special efforts should be drawn in order to reduce as much as possible the rates of ankle sprains, stress fractures of the distal tibia, and knee injuries. Further investigation should be performed in order to discover the reasons for significantly higher rates of ankle injuries among soldiers in the junior commanders training as compared with trainees in the infantry school of officers. The reasons for the surprisingly substantially higher risk for men to get injured as compared with women should be investigated and discovered. References 1 Schwartz O, Libenson T, Astman N, et al.  : Attrition due to orthopedic reasons during combat training: rates, types of injuries, and comparison between infantry and non-infantry units. Mil Med  2014; 179( 8): 897– 900. Google Scholar CrossRef Search ADS PubMed  2 Pope RP, Herbert R, Kirwan JD, et al.  : Predicting attrition in basic military training. Mil Med  1999; 164( 10): 710– 4. Google Scholar CrossRef Search ADS PubMed  3 Knapik JJ, Darakjy S, Hauret KG, et al.  : Increasing the physical fitness of low-fit recruits before basic combat training: an evaluation of fitness,injuries, and training outcomes. Mil Med  2006; 171: 45– 54. Google Scholar CrossRef Search ADS PubMed  4 Technical Bulletin Medical 592. U.S. Department of the Army, Prevention and control of musculoskeletal injuries associated with physical training. Washington, DC, 2011: Page 9. Available at http://armypubs.army.mil/med/dr_pubs/dr_a/pdf/tbmed592.pdf; accessed January 12, 2012. 5 ROSS J: A review of lower limb overuse injuries during basic military training. I: types of overuse injuries. Mil Med  1993; 158( 6): 410– 5. Google Scholar PubMed  6 Cloren M, Mallon TM: Managing workers’ compensation costs in the military setting: the army’s story. Clin Occup Environ Med  2004; 4: 323– 39. Google Scholar CrossRef Search ADS   7 Packnett ER, Niebuhr DW, Bedno SA, et al.  : Body mass index, medical qualification status, and discharge during the first year of US Army service. Am J Clin Nutr  2011; 93( 3): 608– 14. Google Scholar CrossRef Search ADS PubMed  8 Heir T: Musculoskeletal injuries in officer training: one-year follow-up. Mil Med  1998; 163: 229– 33. Google Scholar CrossRef Search ADS PubMed  9 Billings CE: Epidemiology of injuries and illnesses during the United States Air Force Academy 2002 Basic Cadet Training program: documenting the need for prevention. Mil Med  2004; 169( 9): 664– 70. Google Scholar CrossRef Search ADS PubMed  10 Almeida SA, Williams KM, Shaffer RA, et al.  : Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc  1999; 31( 8): 1176– 82. Google Scholar CrossRef Search ADS PubMed  11 Raju KS, Sharma S, Yadav RC, et al.  : An epidemiological study of stress fractures among flight cadets at Air Force Academy. Ind J Aerospace Med  2005; 49: 48– 53. 12 Maddi SR, Matthews MD, Kelly DR, et al.  : The role of hardiness and grit in predicting performance and retention of USMA cadets. Mili Psychol  2012; 24( 1): 19– 28. Google Scholar CrossRef Search ADS   13 Schwartz O, Malka I, Olsen CH, Dudkiewicz I, Bader T: Overuse injuries in the IDF’s combat training units: rates, types and mechanisms of injury. Mil Med  Forthcoming 2017. doi: 10.1093/milmed/usx055. 14 Tomlinson JP, Lednar WM, Jackson JD: Risk of injury in soldiers. Mil Med  1987; 152( 2): 60– 4. Google Scholar PubMed  Author notes The authors declare that all facts and opinions mentioned in this study do not reflect or portray the opinions of the IDF commanders or the Israeli government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Medical Attrition from Commanders Training in the Israeli Defense Forces (IDF): A Cross-sectional Study on 23,841 Soldiers

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Abstract Introduction Attrition from training is associated with substantial financial and personnel loss. There is a plethora of medical literature and research of attrition rates related to initial/phase 1 training (basic combat training); however, the analysis of second phase training (commanders training, consisting of schools that qualify junior commanders and officers for infantry and non-infantry combat units) is limited. The purpose of this study is to perform a comprehensive survey regarding to medical attrition from commanders training in the IDF (Israeli Defense Forces) in order to present the commanders of the IDF a detailed situation report that will serve as an evidence-based platform for future policy planning and implementation. Methods A cross-sectional study including all soldiers (23,841) who participated in commanders training in the IDF in the period of 2012–2015 was performed. Soldiers for whom the attrition reason (medical or not medical) was missing were excluded from this study. Data were collected from the adjutancy-computerized system as well as the IDF’s computerized medical consultation records package (CPR). Descriptive statistics were performed using mean, standard deviation, and median in order to express results. For the determination of statistical significance, chi-square test, Student’s t-test, and Poisson regression models were used. Results Out of 23,841 soldiers that participated in this study, 75% (17,802) were males and 25% (6,039) were females. The overall attrition rate was 0.7% (164). The attrition rate for males was 0.86% (148 out of 17,082 males) and 0.26% (16 out of 6,039 females) for females. After adjusting for training unit, age, and BMI, the risk for attrition was 1.6 (160%) times higher for males as compared with females, and this result was statistically significant (IRR = 1.6, p = 0.01, CI 1.1, 2.2). The re-injury rate was 41% (68 out of 164 soldiers). The three most frequent diagnoses for attrition were orthopedics (66%), general surgery diagnoses (12%), and diagnoses related to internal medicine (11%). Out of 107 soldiers that attired due to orthopedic reasons, 36 (34%) suffered from calf and ankle injuries, 22 (21%) attired due to diagnoses related to the lower back, and 22 (21%) attired due to diagnoses related to the knee region. The highest attrition rate was encountered in the school for infantry junior command (2.2%) and the lowest rate was encountered in the officer training school for non-infantry units (0.11%). After adjusting for age and BMI, the risk for ankle injury was 2.55 (255%) times higher for soldiers in the school for infantry junior command as compared with soldiers in the officer school for infantry units (IRR = 2.55 p = 0.017, CI 1.18, 5.47). Conclusion The attrition rate from commanders training in the IDF is low, and at this point, however, due to lack of uniform criteria for attrition, it cannot serve as an objective measure. We suggest measuring and discussing overuse injury rates (which is the most frequent cause of attrition), instead. Based on our results, we recommend an implementation of a better medical screening policy in order to reduce the re-injury rates during commanders training. INTRODUCTION In the IDF (Israeli Defense Forces), medical attrition is defined as training incompletion due to medical reasons (organic or mental).1 Attrition from training is associated with substantial financial and personnel loss.2,3 The rate of attrition from basic combat training in the IDF is 3.44%, of which, 64% are due to orthopedic and mental diagnoses (43% and 21%, respectively).1 Out of 43% of attrition due to orthopedic diagnoses, 90% are due to overuse injuries,3 and as in other armies, these injuries are the leading cause for medical consultations (more than 50% of all medical consultations).1,4,5 Overuse injuries have the malicious potential of causing severe damage on the personal level in terms of daily function and quality of life. On the day-to-day unit, daily activity, and training cycle, these injuries are the leading cause for lost training days, have detrimental effects in terms of operational effectiveness, and pose a serious economic burden (approximately $2 billion per year in the US Army).2,6–7 Previous research in the IDF found no differences in attrition rates between infantry and non-infantry combat training units (RR = 0.95, p = 0.51).1 There is a plethora of medical literature and research of attrition rates related to initial/phase 1 training (basic combat training); however, the analysis of second phase training (commanders training, consisting of schools that qualify junior commanders and officers for infantry and non-infantry combat units) is limited. A literature review revealed one study on 321 soldiers from the Norwegian army, which demonstrated similar rates of overuse injuries for commanders training as compared with basic combat training.8 The overall overuse injury rate on this study was 25%, and the majority (85%) were in the lower back and the lower limb regions. Similar results were obtained in studies performed in the US Army.9–12 Purpose To perform a pilot survey analysis of medical attrition rates from commanders training in the IDF. To initiate evidence-based strategic policy and intervention programs. METHODS Study Design and IRB (Institutional Review Board) Approval A cross-sectional study was conducted. This study was approved by the IDF’s IRB, approval number: 1203–2012. Population All soldiers participating in commanders training between 2012 and 2015 (total of 23,841 soldiers) in the four commanders training units of the IDF: The school for infantry junior command – qualifying junior commanders to all IDF’s infantry combat units: total number of soldiers: 4,988, training period: 4 mo. The school for non-infantry junior command – qualifying junior commanders to all IDF’s non-infantry combat units: total number of soldiers: 5,790, training period 3 mo. The officer training school for infantry units – qualifying officers for all of the IDF’s infantry combat units: total number of soldiers: 4,741, training period 8 mo. The officer training school for non-infantry units – qualifying officers for all of the IDF’s non-infantry combat units: total number of soldiers: 8,322, training period 5 mo. All soldiers participating in commanders training were found medically fit to serve in combat units according to the medical profile score of the IDF3 and successfully completed basic combat training. Before admission to one of the commander schools, all participants underwent a medical examination performed by the school’s physician in order to establish medical fitness. Soldiers with acute injuries, with physical restrictions due to medical reasons, and soldiers under investigation for medical condition that may influence their ability to fully adhere and complete the training program were not admitted to training. Exclusion Criteria The exclusion criteria include soldiers for whom the attrition reason (medical or not medical) was missing. Data Collection Data were collected from the adjutancy-computerized system as well as the IDF’s computerized medical consultation records package (CPR). We used the adjutancy-computerized system in order to identify all discharged soldiers. After identifying those soldiers, we used the IDF’s computerized medical consultation records package (CPR) to identify the medical reason responsible for the drop out. The following variables were collected: training unit, age, sex, weight, height, BMI, date of training start, date of injury, place of injury (in unit/out of unit), type of medical attrition (organic/mental), body system, and injury site (only for orthopedic/overuse injuries cause of attrition). Orthopedic/overuse injury diagnosis was defined as any medical diagnosis (disease, overuse injury, or trauma) related to the musculoskeletal system. Data Analysis STATA (version 14.0, College Station, TX, USA) and SPSS version 23.0 were used for statistical analysis. Descriptive statistics were performed using means, standard deviations, and medians in order to express results. For the statistical significance of the comparison of two dichotomous variables, the chi-square test was used. For the statistical significance of the comparison of quantitative variables divided into two categories, Student’s t-test was used. Although this is primarily a descriptive study, some associations between exposure and outcome variables were examined. For obtaining these associations after adjusting for potential confounders and the differences in training periods between training groups, Poisson regression models were used expressing the results in IRR (incidence rate ratio). Results In this study, 23,841 soldiers that participated in one of the commander’s training school programs were included: 17,802 (75%) men and 6,039 (25%) women. For detailed distribution of total number of soldiers, injured soldiers, discharged soldiers, and attrition/injured soldiers ratio by training unit, see Table I. No correlation was found between attrition or injury rates and the duration of the training. The lowest attrition rate was observed in the non-infantry officer’s schools with a training period of 5 mo (0.12%), whereas the higher attrition rate was encountered in the infantry junior command school with a training period of 4 mo (1.8%). The highest rate of injuries was observed in the non-infantry officer’s school, 27.6%, with a training period of 5 mo, whereas the lowest injury rate was observed in the infantry junior command, 11.4% with a training period of 4 mo. The rate of injuries in the infantry officer’s school with the longest training period of 8 mo was 22.2%, lower than the injury rate in the non-infantry officer’s school, 27.6%. Table I. Distribution of Total Number of Soldiers, Injured Soldiers, Discharged Soldiers and Attrition/Injured Soldiers Ratio by Training Unit.   SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230      SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230    SIJC, School for Infantry Junior Command; SNIJC, School for Non-infantry Junior Command; OTSIU, Officer Training School for Infantry Units; OTSNIU, Officer Training School for Non-infantry Units. Table I. Distribution of Total Number of Soldiers, Injured Soldiers, Discharged Soldiers and Attrition/Injured Soldiers Ratio by Training Unit.   SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230      SIJC  SNIJC  OTSIU  OTSNIU  Total  Total number of soldiers  4,988  5,790  4,741  8,322  23,841  Number of injured soldiers  567 (11.4%)  1,090 (18.8%)  1,053 (22.2%)  2,301 (27.6%)  5,011  Discharges due to medical reasons  89 (1.8%)  32 (0.55%)  33 (0.7%)  10 (0.12%)  164 (0.7%)  Attrition/injured soldiers ratio  1/6.4  1/34  1/32  1/230    SIJC, School for Infantry Junior Command; SNIJC, School for Non-infantry Junior Command; OTSIU, Officer Training School for Infantry Units; OTSNIU, Officer Training School for Non-infantry Units. For detailed description of sample sizes and injury and attrition rates, see Figure 1. Figure 1. View largeDownload slide Detailed description of sample sizes and injury and attrition rates. Figure 1. View largeDownload slide Detailed description of sample sizes and injury and attrition rates. For details regarding height, weight, and BMI distributed by training completion status, see Table II. Table II. Weight, Height, and BMI Distributed by Training Completion Status.   Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058    Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058  Table II. Weight, Height, and BMI Distributed by Training Completion Status.   Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058    Completed Training  Discharged form Training  p  Weight (kg)  63 ± 1.2  66.8 ± 9.3  0.005  Height (cm)  172 ± 12  174 ± 6.7  0.001  BMI  22 ± 3.2  22 ± 2.7  0.058  The 164 soldiers discharged due to medical reasons were categorized by the medical discipline that the main diagnosis for attrition was established and treated by. Out of the 164 discharged soldiers, 107 (66%) were discharged due to orthopedic/overuse injuries diagnosis, 19 (12%) discharged due to diagnoses related to the general surgery discipline, and 11 (7%) due to diagnoses related to the internal medicine discipline. The frequency of attrition by medical specialty is detailed in Figure 2. Figure 2. View largeDownload slide Detailed frequency of attrition by medical specialty among 164 discharged soldiers. Figure 2. View largeDownload slide Detailed frequency of attrition by medical specialty among 164 discharged soldiers. Out of 107 soldiers that were discharged due to orthopedic/overuse injury diagnoses, 36 (34%) suffered from calf and ankle injuries, 22 (21%) were discharged due to diagnoses related to the lower back, and 22 (21%) were discharged due to diagnoses related to the knee region. Out of 36 soldier discharged due to calf and ankle diagnoses, 31 (88%) suffered from ankle sprains and stress fractures of the distal tibia. Out of 22 soldiers discharged due to diagnoses related to the knee region, 17 (87%) suffered from ACL injury or meniscal tear and were treated by surgery. For detailed breakdown of orthopedic/overuse injury attrition by body site, see Figure 3. Figure 3. View largeDownload slide Frequency of orthopedic/overuse injuries attrition by body site. Figure 3. View largeDownload slide Frequency of orthopedic/overuse injuries attrition by body site. Out of 164 discharged soldiers, 68 (41%) were discharged due to aggravation of a well-known and documented medical diagnoses diagnosed before the beginning of training. After adjusting for age and BMI, the risk for ankle injury was 2.55 (255%) times higher for soldiers in the school for infantry junior command as compared with soldiers in the officer’s school for infantry units (IRR = 2.55, p = 0.017, 95% CI 1.18, 5.47). Training unit did not result as a risk factor for lower back and knee injuries. For detailed Poisson regression model results for the risk for ankle injuries, see Table III. Table III. Poisson Regression Model Results for the Risk of Ankle Injuries. Results Are Adjusted for Age and BMI.   IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)    IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)  Table III. Poisson Regression Model Results for the Risk of Ankle Injuries. Results Are Adjusted for Age and BMI.   IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)    IRR  p-Value  95% Confidence Interval  Officer school for infantry units, N = 4,988  Ref.  Ref.  Ref.  School for infantry junior command, N = 5,790  2.55  0.017  (1.18, 5.47)  Officer school for non-infantry units, N = 4,741  1.17  0.85  (0.25, 5.6)  School for non-infantry junior command, N = 8,322  0.64  0.57  (0.14, 3.02)  The attrition rate for men was 0.86% (148 out of 17,082 men) and 0.26% (16 out of 6,039 women) for women. After adjusting for unit, age, and BMI, the risk for attrition was 1.6 times (160%) higher for men as compared with women (IRR = 1.6, p < 0.001, 95% CI 1.1, 4.2). Discussion The Salient Findings of this Study There are different criteria for attrition between units; hence, attrition rates cannot serve as an objective uniform measure and cannot be compared between units. There is no correlation between injury and attrition rates among all units. There is no correlation between training’s duration and injury and attrition rates. Most of attrition (66%) is due to overuse injuries. Most injuries occur in the lower back, knee, and calf and ankle regions. There are high re-injury rates (41%). There are higher rates of injuries in the infantry officer’s school as compared with the infantry commander’s and basic combat trainings. Men are at higher risk for injury than women. In our opinion, these findings are significant for further decision-making and policy planning and implementation. Each of these findings will be further discussed in details. Attrition Rates Although statistically significant, the differences in height and weight between the attrition group and the group that finished training were minor and practically clinically insignificant (2 cm difference in height and 1.5 kg in weight). We did not find any differences between the two groups regarding other demographic and anthropometric data. The overall rate of attrition from commanders training according to this study is 0.7%. We consider this rate to be low absolutely and relative to attrition rates in basic combat training (2.5%).1 However, as the decision to drop out a soldier is influenced by other considerations rather than the medical condition (such as operational and staffing standards considerations), attrition criteria are not the same for all units. Therefore, we think that attrition rates cannot serve as an objective uniform measure, and attrition rates cannot be compared between units. More than that, as attrition cannot serve as an objective measure, it cannot be discussed without discussing the main cause for medical attrition which is overuse injuries (107 out of 164 soldiers, 66%). Overuse Injury Rates and Comparison to Injury Rates in Basic Combat Training Units The overall injury rate in the IDF’s basic combat training units is approximately 25%, 18% in the infantry basic combat units, and approximately 36% in the non-infantry units.13 As demonstrated in our results, the injury rates in the non-infantry commander’s schools are lower than in the basic combat training of these units (28% in the non-infantry officers’ school and 19% in the non-infantry junior command school). The injury rate in the infantry combat training units is higher than in the infantry commander’s school (18% vs. 11.4%) and lower than in the infantry officer’s school (18% vs. 22.2%). The increase in injury rates in the infantry officer’s school as compared with basic combat and junior commander’s trainings of infantry units is in our opinion worrisome. We expected to find a substantial decrease in injury rates in all second phase of training (commanders schools) as the soldiers selected to this training are usually more experienced with better physical fitness, have higher motivation, and successfully passed the natural selection of the basic combat training. Furthermore, soldiers in the officer’s school are considered to be more responsible, more disciplined, and more aware for injury prevention than soldiers in infantry basic training, and in the infantry junior command, cadets are usually trained by the best physical fitness officers and teams, and the commanders of the officer’s school should be highly aware of the risk of injuries and injury prevention. If we assume that the quality of soldiers and staff is higher in the officer’s schools, the high rate of injuries among cadets in the infantry officer’s school may be explained by other possible reasons as follows: The training program – the bar is set too high – The intensiveness and the physical effort demands of the training program are too high, leading to overtraining and injuries. Over motivation and concealing of information – Due to the fear of not being admitted to the officer’s school, some soldiers are reluctant to report or seek for medical treatment for known injuries or symptoms. However, during the officer’s training, the symptoms and injuries are aggravated and finally reported. Re-injury – as previously mentioned, the re-injury rate in this study was 41%. It might be that previously injured soldiers did not completely heel from their previous injury and were not properly prepared to return to full activity after injury. During the high intensive training in the officer’s school, the vulnerable site of previous injury is exposed to re-injury. Accessibility and availability of medical services – It might be that some injuries were not reported before officer’s school training due to medical service availability and accessibility issues. Our main recommendation regarding the increase in injury rates in the infantry officer’s school as compared with basic combat and junior commander’s trainings of infantry units is an immediate investigation of the reasons for this worrisome increase in injury rates including a comprehensive investigation of the training program. Attrition vs. Injury Rates The highest attrition/overuse injury ratio was observed in the infantry junior command school. These substantial differences in attrition/overuse injury ratio between units may in our opinion serve as a solid evidence to the above statement that attrition cannot serve as an objective measure and cannot be discussed without discussing overuse injuries. Different policies regarding medical attrition may also affect the future risk for injury and the ability to continue and serve in a combat unit. Therefore, we think that a study that examines the rates of injury and discharge from combat units after qualifying a commander’s school is crucial in order to understand the influence of attrition policy on both variables. In this study, we did not find any relation between type of injury and time of discharge (e.g., the time from injury to the decision to discharge). The main reason for this lack of relation is that the decision to discharge is based individually on many cases. For the same injury, there are soldiers that will be discharged and others that will not, depending on many individual or specific factors such as the timing of injury in terms of the training phase, the individual heeling pace, and the amount of lost training days. The latter two are difficult to predict; hence, in some cases, soldiers that were predicted to fully recover and qualify the training will be unexpectedly discharged due to more than expected lost training days. Furthermore, as previously mentioned, the decision of discharge is influenced by other factors rather than pure medical considerations; hence, there is inconsistency regarding discharge policy including discharge timing between units. Duration of Training vs. Attrition and Injury Rates Intuitively, the duration of training should be strongly correlated with both attrition and injury rates. However, the results of this study demonstrate no correlation between the training period and the attrition or overuse injury rates. These surprising results suggest that the period of training plays a secondary role in the risk for injury or attrition. Other factors that may be more correlated with risk for injury and attrition may be related to the quality of training, rather that the training period, such as the physical effort demands, quality and adherence to the training programs by avoiding over or undertraining,4,5,10,14 the quality of the training personnel, and the basic fitness of the trainees. Re-injury Rates The re-injury (repeated injury during commanders training that was well reported and documented before the beginning of commanders training) rate in this study was 41%. This rate in our opinion is high and should be substantially reduced by personal restrictions and training instructions for the pre-injured soldiers, and in unique cases of severe pre-injury, the exclusion of these soldiers from commanders training. In our opinion, according to these findings, a better medical process of screening and selection by the physicians of the commander’s schools should be performed. Basic fitness tests and basic MSK (Musculoskeletal) injury questionnaire may be efficient screening tools that can be used by the screening physician and we recommend the usage of such tools in the admission process of all commanders’ schools. Distribution of Overuse Injuries by Body Site Similar to medical attrition from basic combat training,3 most of the medical attrition in commanders training is due to orthopedic/overuse injury diagnoses (66%) and most of the injuries were in the lower back and lower limb regions. The most frequent body sites for overuse injuries were the calf and ankle (34%) followed by the knee (22%) and the lower back. Approximately 90% of injuries in the calf and ankle regions were ankle sprains and stress fractures of the distal tibia. Approximately 90% of knee injuries were meniscal tears and ACL injuries. These injuries, especially the ACL injury, are considered to be relatively severe injuries, are usually treated by surgery, demonstrate high rates of complications, and are associated with a long period of training loss. Therefore, these injuries will almost always end with discharge and attrition. Based on the above, we think that a special focus and effort should be drawn in order to reduce ankle sprains and stress fractures of the distal tibia mainly due to their high frequency and meniscal tears and ACL injuries mainly due to their severity. Training Unit as a Risk Factor for Ankle Injury We found that soldiers in infantry junior command training have 2.55 higher risk for ankle injury than soldiers in officer’s school for infantry. Explanations for this finding may be: Trainees in officer’s schools are usually more responsible, more disciplined, and more aware for injury prevention. Almost all trainees in officer’s schools usually participate in junior commanders training; hence, the junior commander training serves as a natural screening phase to the officer’s school. Usually, trainees in officer’s schools are trained by the best physical fitness officers and teams and the commanders of the officer’s school are highly aware of the risk of injuries and injury prevention. However, in this context, the overall overuse injury rates are twice as high in the officer’s school as in the junior command. Therefore, it might be that the above explanations play a secondary role in explaining this higher risk and the main factor responsible for this risk is the different components of the training program between the two schools. Nevertheless, in order to establish the exact reasons for the higher risk for ankle injury in the junior commander training as compared with the officer’s school, further investigation by analytic studies is necessary. Attrition Due to Mental Diagnoses The attrition rate due to mental diagnosis was 3%. This number is absolutely and relatively low as compared to the rate in basic combat training (21%). This low rate may be explained by the fact that soldiers selected to the commanders training are more mentally resilient than recruits, and as commander training in the IDF is voluntary, the motivation of these soldiers is usually high, which substantially contributes to the mental resilience. Sex Differences In our study, men have 1.6 times higher risk for injury as compared with women. This finding is surprising as female gender is considered to be one of the major risk factors for injury. Thirty-three percent of all soldiers in the IDF are women; of them, 7% are warriors in combat units. Ten percent of all warriors are women, most of them serving in the field intelligence force and the mixed battalions performing duties of borders keeping. One explanation for the higher risk of injury for men as compared with women may be the fact that only those women with highest levels of motivation and physical fitness will be assigned to command training. Other explanation may be provided by the fact that most women are assigned to the officer’s school for non-infantry units in which the training program and the required physical demands and efforts are much lower than in the infantry commander schools. Nevertheless, as a result of the implementation of the Israeli government’s decision to equally open for men and women all combat duties in the IDF, the number of female warriors is expected to substantially increase and the duties they serve may be much more varied. As a result, much more women are expected to be assigned to the other commander’s schools rather than the non-infantry officer’s school. This may substantially change the risk for women to be injured as compared with men. Study’s Advantages and Limitations The main advantage of this study is the population size, which enables detailed situation report and characterization of the medical attrition from commanders training. However, this study has limitations: It is a descriptive and cross-sectional study; hence, causality between exposures and results could not be properly assessed. There was no blinding, so bias in reporting or data collection cannot be excluded. The risk from incorrect original data entry may be a profound limitation: There is a great variety between physicians and medical personnel regarding to medical recording and diagnoses documentation; hence, there is a lack of uniformity regarding the documentation of medical consultations. This lack of uniformity may reduce the quality of data and create difficulties in data collection and analyze. The time from training beginning to date of attrition/injury was missing in more than 50% of participating soldiers. These missing data did not allow us to use a Cox model, which is the best way to account for the substantial differences in the duration of training between the different schools. We partially overcome this issue using a Poisson model with the duration of training expressed in person months as the offset variable. However, using Poisson models for our data had some disadvantages such as the variable types and overconfidence. Furthermore, these missing data did not allow us to understand if there is a pivotal duration when injury occurs. Lack of quality research in this field to draw upon or compare too. Conclusions and Recommendations The population size of this study enabled us to produce a detailed situation report with several significant findings that can serve as a solid base for policy planning and implementation and further investigation Better specificity of recording and data management are required for better analysis of data in future research. The attrition rate from commanders training in the IDF is relatively low, and at this point, however, the results of this study suggest that attrition cannot serve as an objective measure for the soldier’s health nor for the rates of overuse injuries. Uniform criteria for medical attrition should be formulated by the IDF commanders. Those criteria should be mostly based on medical decisions. A study that examines the rates of injury and discharge from combat units after qualifying a commander’s school should be conducted. A better medical screening policy should be planned and implemented in order to reduce the rates of re-injury during commanders training. Basic fitness tests and basic MSK (musculoskeletal) injury questionnaire should be considered as some of the screening tools. An immediate investigation of the training program in order to verify whether the bar is set to high should be performed in the infantry officer’s school. Special efforts should be drawn in order to reduce as much as possible the rates of ankle sprains, stress fractures of the distal tibia, and knee injuries. Further investigation should be performed in order to discover the reasons for significantly higher rates of ankle injuries among soldiers in the junior commanders training as compared with trainees in the infantry school of officers. The reasons for the surprisingly substantially higher risk for men to get injured as compared with women should be investigated and discovered. References 1 Schwartz O, Libenson T, Astman N, et al.  : Attrition due to orthopedic reasons during combat training: rates, types of injuries, and comparison between infantry and non-infantry units. Mil Med  2014; 179( 8): 897– 900. Google Scholar CrossRef Search ADS PubMed  2 Pope RP, Herbert R, Kirwan JD, et al.  : Predicting attrition in basic military training. Mil Med  1999; 164( 10): 710– 4. Google Scholar CrossRef Search ADS PubMed  3 Knapik JJ, Darakjy S, Hauret KG, et al.  : Increasing the physical fitness of low-fit recruits before basic combat training: an evaluation of fitness,injuries, and training outcomes. Mil Med  2006; 171: 45– 54. Google Scholar CrossRef Search ADS PubMed  4 Technical Bulletin Medical 592. U.S. Department of the Army, Prevention and control of musculoskeletal injuries associated with physical training. Washington, DC, 2011: Page 9. Available at http://armypubs.army.mil/med/dr_pubs/dr_a/pdf/tbmed592.pdf; accessed January 12, 2012. 5 ROSS J: A review of lower limb overuse injuries during basic military training. I: types of overuse injuries. Mil Med  1993; 158( 6): 410– 5. Google Scholar PubMed  6 Cloren M, Mallon TM: Managing workers’ compensation costs in the military setting: the army’s story. Clin Occup Environ Med  2004; 4: 323– 39. Google Scholar CrossRef Search ADS   7 Packnett ER, Niebuhr DW, Bedno SA, et al.  : Body mass index, medical qualification status, and discharge during the first year of US Army service. Am J Clin Nutr  2011; 93( 3): 608– 14. Google Scholar CrossRef Search ADS PubMed  8 Heir T: Musculoskeletal injuries in officer training: one-year follow-up. Mil Med  1998; 163: 229– 33. Google Scholar CrossRef Search ADS PubMed  9 Billings CE: Epidemiology of injuries and illnesses during the United States Air Force Academy 2002 Basic Cadet Training program: documenting the need for prevention. Mil Med  2004; 169( 9): 664– 70. Google Scholar CrossRef Search ADS PubMed  10 Almeida SA, Williams KM, Shaffer RA, et al.  : Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc  1999; 31( 8): 1176– 82. Google Scholar CrossRef Search ADS PubMed  11 Raju KS, Sharma S, Yadav RC, et al.  : An epidemiological study of stress fractures among flight cadets at Air Force Academy. Ind J Aerospace Med  2005; 49: 48– 53. 12 Maddi SR, Matthews MD, Kelly DR, et al.  : The role of hardiness and grit in predicting performance and retention of USMA cadets. Mili Psychol  2012; 24( 1): 19– 28. Google Scholar CrossRef Search ADS   13 Schwartz O, Malka I, Olsen CH, Dudkiewicz I, Bader T: Overuse injuries in the IDF’s combat training units: rates, types and mechanisms of injury. Mil Med  Forthcoming 2017. doi: 10.1093/milmed/usx055. 14 Tomlinson JP, Lednar WM, Jackson JD: Risk of injury in soldiers. Mil Med  1987; 152( 2): 60– 4. Google Scholar PubMed  Author notes The authors declare that all facts and opinions mentioned in this study do not reflect or portray the opinions of the IDF commanders or the Israeli government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Military MedicineOxford University Press

Published: Mar 14, 2018

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