The theme of readiness is prominent in the 2020 Posture of the United States Army Statement, in which senior Army leaders emphasized to the Senate Armed Services Committee that warfighting readiness remains the Army’s top priority as it increases lethality to prepare for the future. A key element is that soldiers must be ready to deploy and able to train.
Injuries, and specifically musculoskeletal (MSK) injuries, are the most significant medical non-readiness factor in the U.S. Army, according to Army Public Health Center (APHC) experts and the Army’s “2018 Health of the Force” report. Research has shown that these are primarily due to cumulative trauma, or overuse injuries, including stress fractures, Achilles tendonitis, patellar-femoral syndrome, plantar fasciitis, and back and knee pain syndromes. They are mostly sustained from training and strenuous operational activities, reflecting actions necessary for mission preparedness, with running the leading cause of MSK injuries.
To tackle this problem, Army Wellness Centers (AWCs), an integrated network of 35 facilities located across the United States and overseas, are utilizing research combined with technology, health promotion, and wellness programs to minimize soldiers’ MSK injury risk factors. AWC services include metabolic testing, fitness testing, body composition analysis, biometrics, biofeedback, health coaching, and health education.
The AWCs were designed and implemented around 2005, with the last implementation completed about 2018, according to Laura Mitvalsky, director of Health Promotion and Wellness, APHC. “It was the Army’s response to fragmented health promotion program delivery,” she said. “We actually did a largescale evaluation looking at health promotion and wellness programs across the Army, and they’ve done that in the DOD [Department of Defense] as well. What they found was that there are a lot of programs out there, but they can’t be evaluated because they don’t have the component pieces in place to be evaluated.”
The AWCs were devised to address that fragmentation, Mitvalsky explained, by building a standardized model to look at not only the facilities, but also programs, staffing, and equipment. “That standardized model delivers key readiness support capabilities to soldiers and community members. And they do that in several ways,” she said. “Typically, health promotion and wellness programs are based on the disease, like a high blood pressure class or a high cholesterol class or weight management. But that’s not how the wellness centers program standardized model is designed. It’s based upon targeting the behaviorally modifiable factors most likely to result in chronic disease, injury, and/or performance issues. So, our core programs are based upon, ‘How do we get after the behaviors that lead to those problems?’”
In addition to the distinctive program model, Mitvalsky also described AWC staff as unique, composed of a variety of allied health sciences professional backgrounds and national certifications, and cross-trained in health coaching applications “so that they have competencies in all of the assessments that we do in the wellness center.” So, for example, an exercise physiologist can also do the metabolic testing, or a registered dietician is cross-trained to do exercise testing.
Along with active-duty service members, the AWCs also provide standardized primary prevention programs to adult family members, retirees, and Department of the Army civilians. In 2019, the wellness centers served more than 58,000 unique clients with approximately 119,000 combined total visits. The majority of those were active-duty soldiers at about 77 percent, followed by family members at about 11 percent.
Decades of Army injury prevention research have led to knowledge of the scope of the injury problem and its risk factors that are addressed by the capabilities of the AWCs. Bruce Jones, MD, MPH, senior scientist in the APHC Clinical Public Health and Epidemiology Directorate, described the magnitude of the injury problem: “Musculoskeletal injuries are the biggest health problem in the Army, resulting in over 2 million medical encounters annually, and accounting for very close to 10 million limited duty days,” he said, adding that the second leading problem, behavioral health, is about a million visits, and less than 2 million days of limited duty. “So, this is really the Army’s biggest health concern.”
Research shows the strong connection between both aerobic fitness and body composition as related to increased risk for MSK injury. The risk factors can be quantified in terms of slow 2-mile run times and body mass index ratings out of compliance with the Army Body Composition Program, Army Regulation 600-9, either too low or too high. But the primary MSK risk factor is slow run time, meaning males with a 2-mile run time greater than 15 minutes or females with a 2-mile run time greater than 18 minutes.
“Low aerobic fitness is the most consistent risk factor that we found,” Jones said. “We also know that high and low body fat are risk factors, especially when coupled with low aerobic fitness,” but, he added, there are also other risk factors, including smoking, poor sleep, and stress. “We’ve shown over the years that the more you smoke, the more you get injured, and those who are heavy smokers have risks that are one-and-ahalf to two times higher than soldiers who don’t smoke. We also know that individuals who sleep less than four hours a day have a 50 percent higher risk than those who sleep eight or more. And we can show that individuals who have higher-than-usual stress have a one-anda-half times higher risk than those who have less-than-usual stress.”
Jones said that the AWCs addressed many of these risk factors because they relate to long-term health as well, “but now we have a focus on something that’s much more immediate and has a bigger impact on the Army – and that’s musculoskeletal injuries.
“We realized in working together that many of the most important [MSK] risk factors that we have found, low aerobic fitness for instance, and high or low body composition, were things that the wellness centers were already looking at. So, it really became an ideal partnership to begin working together,” Jones said, “because in the wellness centers, we have a platform to build on and get the information out, especially to the highest risk populations.”
Mitvalsky added, “When we started the wellness centers, we were focused on chronic disease and long-term health outcomes, and as the [MSK research] data has become more available, we can actually target those soldiers with those risk factors and get them into the wellness centers. And that’s our focus now.
“We’re trying to make it really easy for commanders to know who to send to the wellness centers,” she said.
“What the wellness centers provide to individual soldiers is a place that they can go for a personalized assessment that’s scientifically validated and get a personal prescription for how to improve multiple components of their health and their performance,” Jones explained. “Because not only will these things reduce injury risks, but also by improving your run times, you’re going to improve your military performance. And we know that performance on military obstacle courses, for instance, is better among soldiers who have higher aerobic fitness. So, there are multiple benefits to the individual soldier.”
Luis Omar Rivera, PhD, Army Wellness Center lead program evaluator in the APHC Health Promotion and Wellness Directorate, explained how the AWCs work to reduce soldiers’ risk of MSK injuries. “We know from multiple years of Army injury prevention research that low aerobic fitness and poor body composition – having too high or too low body fat percentage – are very strong predictors of musculoskeletal injury,” he said. “The wellness centers are applying the knowledge that we have from that [research] to help soldiers prevent musculoskeletal injuries before they occur, and it really all starts with the Army Wellness Center health educators’ use of technology. The health education staff within the wellness centers use cutting-edge aerobic fitness testing and body composition technology to assess where soldiers currently stand on those measures and to provide soldiers with feedback about where they stand. Staff then work with soldiers on an individual basis to help them make improvements to the underlying behaviors that we know contribute to low aerobic fitness and poor body composition.”
Rivera continued, “This includes what the Army refers to as the performance triad of sleep, physical activity, and nutritional behaviors. These are three key behaviors that have a synergistic effect on soldier health and readiness outcomes, and the wellness center staff use health education and health coaching techniques to help soldiers create an improvement plan around these behaviors, to help them ultimately reduce their musculoskeletal injury risk.”
Jones added, “And if you think about it, you can increase your aerobic fitness by training not only on the track, but also at the dinner table. So, they can get in one place both coaching on improving their physical activity and thereby their fitness, and also on nutrition as well. And not only can these high-risk soldiers go there, but if commanders are aware of soldiers who are concerned about sleep or smoking cessation or stress, they have a place that they can go to address their concerns on an individual basis.
“I think a surprise to many is the fact that activity, body composition, sleep, tobacco, are all related to injuries, and how big an impact they have,” Jones continued, adding that it’s also important to realize that you don’t have to wait 30 or 40 years to experience the ill effects of smoking or being overweight.
The AWCs continue to expand their capabilities with the new K5 technology, a research-grade assessment device currently being tested at many of the facilities. Rivera explained, “The wellness centers are in the process of taking their aerobic fitness assessment capabilities truly to the next level, partnering with university researchers to implement the latest in wearable metabolic testing technology to assess aerobic fitness in field-based settings. Currently, wellness centers are limited to assessing aerobic fitness in the facility, in the actual center itself. With this new wearable, portable technology, they’ll be able to do that in the field,” and, he added, better support readiness by delivering this fitness testing capability to soldiers in their training environments. Mitvalsky added, “We are cutting-edge right now and developing the protocols with the universities that we’re partnered with, so not only will the Army have this technology, but industry will have this technology as well.”
“We should also be able to identify the components of what the AWCs do that are the most effective,” said Jones. In utilizing the K5s in field assessments, “it may be that we don’t just look at running, but we could also look at activities like marching [to ascertain] who are the soldiers who are going to have difficulty carrying a 70-pound rucksack. So, there is great potential, not only from a health promotion perspective, but actually from a scientific perspective, knowing what works best.”
For all the program and research components, a key aspect of the AWCs is that they are standardized and function with a centralized database, where every facility is executing the programs’ components in the same manner and on the same equipment. That’s essential, Jones said, “because if you don’t have standardization, you can’t move from installation to installation as soldiers do, and know whether you’re improving, and have the providers who are seeing you know whether you’re improving, as a basis for counseling. And the other factor that’s very critical is a centralized database.”
Echoing that concept, Rivera said, “We really take an enterprise-level perspective to evaluation, where we are able to look at the soldier’s experience with the wellness centers regardless of where they are physically located. So, as they move from installation to installation, and they continue to come to the wellness center, we can continue to track that trajectory. The value of that is that we see a more comprehensive picture of how soldiers are changing over time.”
Noting that the AWCs are based on a standardized, replicable model, and moreover, that “commanders love the wellness centers, and we are constantly getting requests to put up more,” Mitvalsky said one challenge, as with many things, is: “How do we resource those?” She added that it’s imperative to continue reinforcing to commanders that “if you send your soldiers to that wellness center, that is going to be a good use of their time.”
Mitvalsky indicated that, as additional evidence of AWC acceptance, the Navy and the Air Force have inquired about developing wellness centers using the same model. “So, do we export across the DOD so that no matter whether a soldier, sailor, airman, Marine, they could get these services wherever they go? We’re starting to have [those] discussions,” she said.
“I believe the key message is that the Army Wellness Centers are an investment in the health of our force, not only as a whole, but also at the individual soldier level,” Mitvalsky concluded. “Because it’s really at the individual level that we can provide specific information on their physiology to help them improve their performance. The foundation of all of that is the Army’s ability to deploy, to fight, and to win against any adversary, and that comes down to the individual soldier being able to do what they need to do when they need to do it. The components of the Army Wellness Center, the assessments that we do, are going to help them achieve that goal.”