A. The Issue: All wounded, injured and ill Soldiers are assigned to Warrior Transition Units (WTUs) to heal sufficiently before returning to duty or transitioning to veteran status. Throughout the Army, the number of Soldiers assigned to WTUs tops 10,000, distributed among 35 WTUs. Over 500 Soldiers are assigned to four WTUs in Germany, two of which operate within the Kaiserslautern Military Community (KMC): Kleber and Baumholder. Most of the Soldiers in WTUs are in what is called Complex Care (CC), meaning they are still receiving regimented treatment and it is not clear whether they will meet retention standards and return to duty or proceed to their medical boards. The WTU mission is to facilitate the healing and rehabilitation of Soldiers, return them to duty when possible, or prepare them for a successful life as veterans in their community40. The Soldiers assigned to WTUs have a mission as well: “If they’re not healing, they’re not doing their job" stresses Brig. Gen. Mike Tucker, the Army’s assistant surgeon general for warrior care and transition39. Now how best to insure WTU Soldiers' stamina and strength steadily progresses from the time of their injury or trauma - how best to focus these Soldiers' efforts on recovery and to facilitate their development of a clear vision of life after healing? WTU Soldiers need a regular fitness regimen endorsed and supported - even shared by close family members.
B. A Unique Requirement: Much is understood and even unconditionally accepted concerning the health, lifestyle, and physiological benefits of regular physical activity for the general population. Daily fitness prescriptions and coaching methodologies are critiqued ad nauseam online, with an overabundance of certifications and full gamut of resources for teachers and trainers presented. Research is not as abundant, but very positive in the affects of physical activity on the disabled, according to accounts of researchers exploring fitness capability or prescribing fitness standards for the benefit of those impaired. Examining data researched and reported online, it was easy to find a vast consensus of overwhelming benefit for disabled who participated regularly in physical activity. In August, 2007, the American Heart Association published updated recommendations for activity and health in adults and older adults, but failed to address specifically the 54.4 Americans with disability. That's a full one-fifth of the US population left out of consideration, one-tenth of whom are considered seriously disabled (meaning they can't function without physical or mechanical assistance). It is true that specialized needs of disabled athletes can't be reproportioned to fit neatly in any sort of cookie-cutter programming prescription, so drafting an all-inclusive health and activity advisory for them would present an imposing challenge. Fitness programs for disabled patrons have unique requirements which often tax the resources of administers, including the necessity of providing individualized training regimens. Group workouts are not completely out of the question but certainly pose a greater challenge to administer: athlete-to-trainer ratio is often double or more by necessity to minimize risks.
C. Fitness Importance in WTUs: The importance of fitness for WTU Soldiers deserves prominent support.
1. Scientific research and lessons-learned cited by health care professionals and certified sports conditioning coaches indicates near-immediate improvement following introduction of weekly fitness regimens. A report published in 1999 on physical activity and health among people with disabilities indicated that optimizing their physical activity is critical to their general welfare:
People with disabilities who may be close to or below the threshold of being able to manage basic activities of daily living (ADLs) and the functions necessary for their accomplishment are at particular risk of inactivity (i.e., may be more prone to sedentary lifestyles). Even small reductions in stamina or capacity can negatively impact the ability to dress, bathe, eat, or walk without assistance (3). The loss or reduction in independence in such basic activities hampers personal freedom, reduces autonomy, and leaves the person more vulnerable to the detrimental physiologic and psychological effects of, and secondary conditions associated with, physical inactivity. Loss of such independence also impacts strongly on the costs of and need for long-term care services31. It should come as no surprise that there is still open admission among Soldiers in WTUs that they struggle daily to fight gravitation toward activities such as video games and television which perpetuate addiction to the "mindless rut" of temporary escape35.
2. Soldiers in WTUs arguably need the daily routine and discipline required of a rigorous fitness program the most of all. Our Soldiers in KMC WTUs have shown enormous motivation about pursuing fitness. When their pursuit is bolstered by additional incentives such as better standards of living and lower long-term care costs, the government's provision of quality fitness training for these Soldiers should be elevated in priority and directly addressed.
Three phases are recommended for implementation of FamFit into WTUs:
Phase 1: Implement Quadrant of Care Protection for each WTU Soldier
The Triad of Care treatment team currently assigned to the Army's most severely wounded Soldiers includes three categories of professionals: a physician, nurse care managers, and military squad leaders. WTU rehabilitation would be radically more effective when administered by Care Quadrants. A critically important aspect of healing Soldiers is reshaping their focus to the extent every bit of their concentration, energy, and expectations is directed into personal recovery. By expanding the Triad of Care to include a Warrior Athlete Fitness Trainer, the resulting Quadrant of Care confers automatically greater emphasis on Soldier recovery. [Warrior Athlete Fitness Trainers are appointed by an Adult Health Educator in the FamFit plan - see Encl 3, Chain of Responsibility for Health Educators at http://militaryfamilyfitness.blogspot.com/. Specifics concerning requirements for their appointment of Warrior Athlete Fitness Instructors would need to be added to Encl 2 Adult Health Educator position description].
Twelve researchers working out of the Human Engineering Research Laboratories, Virginia in 1999 introduced the alarming concept of "a cycle of deconditioning" commonly caused by disabilities "in which physical functioning deteriorates, leading to further reduction in physical activity levels31. Not only is there a risk to degenerating physical functioning, there is a risk of disease vulnerability31. Soldiers in WTUs warrant the precautionary assignment of a personal Fitness Trainer, not only for the rationale of risk management but also on the principle that it provides them with a proven lifestyle enhancement while quite possibly saving a significant chunk of long-term care costs as patients build muscular strength, gain self-reliance, and build disease resistance.
Very recently, Tricia Groenheim met the Commander of the Kleber WTU while she was instructing a water aerobics class for the general public on Ramstein Air Force Base. Tricia Groenheim is an American Red Cross volunteer who has donated 1000+ hours and over 400 classes since May '07, teaching indoor cycling to the general community and unit/squad-level PT classes, training other volunteers, and assisting the Health And Wellness Center (HAWC) with active duty members on profile.
Her conversation with the WTU Commander was involved and quickly became animated as the idea emerged to offer other forms of exercise specifically programmed to meet the special needs of his WTU population of Soldiers, utilizing the volunteer instructors Tricia had been coordinating for the past two years (a group of Red Cross volunteer instructors currently teach indoor cycling and body sculpt on base at Ramstein, free of charge).
Tricia and the WTU Commander immediately saw the importance in offering alternative and personalized fitness options to assist Soldiers in recovery. Soldiers are assigned to WTUs because they cannot function in a "standard" Army environment consisting of regular PT training and 8 hr work days due to their daily care requirements, their medical appointments, and other issues. Generally they are also unable to perform standard military physical workouts (running, push-ups, crunches, etc). Current care providers in the KMC admittedly have only a limited-range fitness training plan to facilitate WTU Soldier recovery. As K Malone, an occupational therapist at the Kleber WTU, explains, their goal is simply to "continue to offer the WTU Soldiers opportunities to help them through this healing phase of their lives as best we can."
These Soldiers need the consistency and security of a daily exercise regimen, and the certainty of long-range fitness programming provision.
A "Care Quadrant" puts new emphasis on rehabilitation and reintegration for Soldiers in WTUs. Personalized attention and progressive fitness programs increase morale, enhance positive lifestyle outlook, and improve individual perceptions of care. When Soldiers perceive that the treatment team not only is fully invested but concentrated in achieving their recovery, they will themselves invest more in their recovery and reap the benefits of more accelerated and comprehensive success. The impact of this "Care Quadrant" to Soldiers' eager investment and perseverance in their own rehabilitation and reintegration has been proven here locally in KMC, and also by documented research.
Smith (1993) reported cardiovascular health, improved health maintenance, coordination, flexibility, weight control, and muscular strength were all physiological benefits of sport and physical activity for people with physical disabilities...Several researchers (Coyle, Kinney, & Shank 1991; Patrick, 1986; Sherrill, Hinson, Gench, Kennedy, & Low, 1990; Smith, 1993) reported athletic participation [of disabled] resulted in psychological benefits, including reduced depression and anxiety, perceived competence, increased self-efficacy and self-confidence, self-concept, increased acceptance of disability, and general well being. In addition, Kleiber, Ashton-Shaeffer, Malik, Lee, and Hood (1990) concluded involvement in competitive sports for people with disabilities seemed to have an impact on improving social interactions at home, acquiring friends, and improving physical coordination, strength, endurance, and self-confidence30
Phase 2: Introduce FamFit, an Individually-Programmed Fitness Regimen, to Challenge all Soldiers in WTUs.
The current services offered WTU Soldiers in what Brigadier General Mike Tucker termed a "Comprehensive Care Program" include educational and vocational training, relationship coaching and behavior health treatment. Their care also includes Occupational Therapy and Physical Therapy. Here locally in the KMC, a fitness regimen has proved to be a logical, and necessary inclusion to these services.
Primary Care Managers clear each WTU Soldier before they start fitness classes - currently water aerobics and yoga are offered. Volunteer fitness trainers from the American Red Cross consult with Occupational Therapists and Physical Therapists about each Soldiers' individual "profile" and fitness challenges. Soldiers are prescribed individual routines usually in group settings, taking their current skill levels into consideration and regarding their safety as paramount concern. Volunteer fitness trainers are prepared at any time to further scale workouts down in order to accommodate individuals.
Although much research remains to be done to establish best practices in properly designing exercise programs for disabled patrons, I was still able to easily find a sizeable amount of advice and lessons-learned from coaches with qualified experience online. Warrior Athlete Fitness Instructors need a full report from Care Providers of all the physical, cognitive and social challenges surrounding Soldiers they're assigned. All the more reason to promote Warrior Athlete Fitness Instructors to the fourth position in the WTU Soldier's Quadrant of Care, as it will facilitate critical communication with other members of the Quadrant. An athlete with a physical disability may have difficulty with movements, a low fitness level, or hyperactivity41. Cognitive deficits may include learning delays, short attention span, difficulty with abstract concepts, and difficulty with transfer of learning41. Social aspects of athletes with disabilities include resistance to change, difficulty with transition and routines, difficulty following standard behaviors, ease of frustration, and overriding fear of failure41.
Warrior Athlete Fitness Trainers can facilitate forward-thinking rehabilitative progression of WTU Soldiers in their care by programming challenging yet achievable fitness objectives, taking measured risks with exercise prescriptions within the bounds of safety, providing constructive feedback, and keeping methodical records tracking accomplishment of Soldiers' goals.
Key requirements of Warrior Athlete Fitness Instructors working with WTU Soldiers:
• Approach Soldiers as athletes - treat them equally as athletes - and cultivate atmosphere of acceptance and team spirit.
• Develop short-term achievable objectives in conjunction with their Occupational Therapist's/Physical Therapist's projected timeline for healing, and their own perception of ability.
• Allow Soldiers to experience risk, failure, and success in a controlled, nurturing environment. Do not overprotect, but be aware of unique needs of ill, injured, and disabled athletes in order to reduce injuries and maximize participation.
• Program time at the conclusion of each workout for Soldiers to update their individual fitness logs. Logs record individuals' progress at successfully executing proper movements in strength building, gymnastics, and sport. Push Soldiers progressively and attentively each session to break their personal records.
• Arrange opportunities for Soldiers to compete in Installation-level competitions to publicize their achievements (find ways to match athletes with comparable abilities). Open up eligibility to the local German population when possible in order to enrich the playing field, inspire internationally, and share in celebrating extraordinary possibilities for human performance.
• Focus on what athletes can do, and not on their restrictions.
No amount of services, training, or therapy will provide the WTU Soldier with the positive characteristics he or she will gain while consecutively setting and reaching fitness goals - characteristics include self-assurance, confidence, heightened feelings of self-worth and self-image, and restoration of contentment in living - identical to benefits attained by any other athlete.
Phase 3: Involve Family members and the community directly in the healing process.
WTU Soldiers need a regular fitness regimen endorsed and supported - even shared by close family members. Warrior Athlete Fitness Instructors will invite and encourage a maximum level of family member participation and assistance during fitness sessions. They will provide skilled training to family members which will empower them to safely monitor and assist Soldiers' execution of resistance exercises so long as those exercises are deemed safe to execute unsupervised by a licensed trainer.
The benefits of involving family members in Soldier treatment and rehabilitation can not be overstated. Allowing family members this opportunity to get directly involved in their loved one's recovery will provide improved understanding of their loved one's physical limitations, and promote improved communication with greater empathy. Familiarity with simple, effective, and acceptable exercises for the Soldier allows the Soldier's family member to become more understanding of their capabilities and restrictions. This minimizes overestimation and underestimation of the Soldier's capability, both of which can prove detrimental to Soldier rehabilitation: overestimation encourages feelings of inadequacy and underestimation hinders progression.
When families are also personally invested in the solution - when they are convinced of the long-term positive impact of a healthy lifestyle on their lives, are educated themselves in the cumulative effect of smart choices which support fitness development, and are also led through the difficult initial phase of establishing healthy habits supporting fitness maintenance, the likelihood of long term perseverance for Soldiers radically increases. It should concurrently not be hard to understand why offering fitness training to all predisposed family members in a similar program as the WTU Soldier (whether it is water aerobics, yoga or CrossFit, all scaled accordingly for ability) will actually decrease probability of individual family member attrition. Family members have unmatchable influence on one another's venture attempts, completion, as well as their abandonment. Wounded and ill flourish under encouragement urging sequential achievements of strength goals and endurance milestones. The adage "Recruit the Soldier, Retain the Family" recognizes that support from family members is essential - - this applies not only to recruitment and retainment but also when promoting any major lifestyle change or commitment!!
Especially in the scope of WTU Soldiers' psychological health, or issues regarding traumatic brain injury sustained, scientific research indicates that regular activity conducted in a community setting improves mental health:
In 2 studies it could be demonstrated that group-administered aerobic exercise plus counselling was more effective in the treatment of depressive disorders than counselling alone. Cross-sectional community studies clearly reveal that after controlling for potential sociodemographic and health-related confounding variables the risk of depression is significantly higher for physically inactive individuals compared with regular exercisers. Depression risk is reduced even more markedly when regular exercise is performed in a group or social setting42.
It is essential that Soldiers in WTUs are integrated as much as possible into the military and even the local community. There is currently, at least in the KMC area, a very small number of families who participate in advertised events. FamFit events unequivocally cater to families and would therefore be more successful with family involvement.
FamFit fitness events provide very direct, personalized involvement of willing family members in fitness sessions and confer all associated benefits of exercise on them all individually, including but not limited to enhancing energy levels, muscle mass, joint strength, bone density, self-esteem, while reducing fat and stress levels. Multiple studies including one recently released from Oxford University suggest "that endorphin release is significantly greater in group training than in individual training even when power output, or physical exertion, remains constant...this endorphin release may be the mechanism that underpins the sense of communal belonging that emerges from activities such as religious rituals, dancing or laughing"43. WTU Soldiers will share the gym with family members and other athletes, and this model of exercise with social interaction has proven to positively impact achievement of personal fitness objectives. FamFit's implementation on installations which support Warrior Transition Units would draw more family members in as well as increase awareness of the unit and its mission.
Health Educators will be held legally responsible [and this responsibility must be added to the Encl 2 Adult Health Educator position description] with expanding participant categories in Installation-level Competitions to insure eligibility and involve all interested WTU Soldiers. The "Individuals with Disabilities Education Act IDEA, 1990, Section 504 of the Rehabilitation Act of 1973, Amateur Sports Act, 1978, Americans with Disabilities Act ADA, 1990, as well as minimal ethical values "require every consideration be given to including individuals with disabilities in all ... programs and community activities to the maximum extent possible"28.
Professional consultation is available via nonprofit organizations BlazeSports America and US Paralympics - both of these organizations have pledged to assist Military Wounded Soldiers regardless of their status or location, and for this purpose are currently compiling comprehensive lists of program resources and information in sports and recreation possibilities for disabled athletes. Wheelchair Sports USA (WSUSA) has international teams and will sanction international events. Health Educators must explore coordinating provision of WSUSA-sanctioned events and even opening up races to local disabled athletes.
In 1998 more than 3 million athletes with physical and mental disabilities were involved annually in athletic competitions in the US: "sports allow the [disabled] participant to be part of a team, develop skills, meet new challenges, and achieve goals"44. The richer and more varied the playing field, the more beneficial to disabled and injured Soldiers, as aspirations as well as friendships grow from opportunities to interact with people who share common goals and share challenging pasts. Sharing personal records and comparing training methods in a competitive setting will invariably insure WTU Soldiers continually set the bar higher for themselves.
Final Argument for Integrating FamFit into WTUs
Our numbers of injured and severely disabled in America have sharply increased as a consequence of more troops in harm's way. With unprecedented survival rates and as people with disabilities live longer, the need for addressing long-term health issues for Soldiers with disability must receive greater attention.
It is essential that a Warrior Athlete Fitness Instructor be assigned an active role as part of the professional treatment team tasked with rehabilitating and reintegrating the Army's most severely wounded and disabled Soldiers. Volunteers have been overwhelmed with the enthusiastic response of WTU Soldiers to personalized fitness classes in the KMC region, although family participation in conjunction has not yet been attempted.
The WTU fitness classes are just beginning. Water instructors conducted preliminary planning meetings in late-May 2009, but initial administrative delays including final authorization of multiple Memorandums of Understanding postponed program commencement for months, and then recently a complete pool closure due to maintenance issues pushed resumption of regular programs back to Tuesday 22 Sept. WTU Soldiers have expressed constant impatience to volunteer fitness instructors and their care providers throughout this time about getting in the pool to workout. Yoga and tai chi classes also began the week of 21 September. WTU Soldiers in the KMC are offered free water aerobics instruction 2 days per week, yoga 2 days per week, and tai chi once weekly. As the Soldiers progress in fitness ability, volunteer trainers will offer more core conditioning classes and eventually take the strongest Soldiers with the greatest chance of complete Recovery To Duty (RTD) on the indoor climbing wall.
There is no tolerance of inexperience on the part of Warrior Athlete Fitness Trainers who hold the responsibility of prescribing fitness routines to injured, ill, or disabled Soldiers: having a background of knowledge in coaching athletes with disabilities could save that athlete's life during critical situations41. Fitness Trainers are ultimately responsible for the safety of their Soldier clients while conducting fitness training, and consequently need to be intimately familiar with key traits of each disability including limitations of involved musculature and limbs, and risks inherent following introduction of fitness stressors such as weights, oxygen deprivation, and cardiorespiratory exertion. WTU Soldiers need certified Fitness Trainers and qualified, individualized workouts, and for safety reasons these aspects of their fitness programming are nonnegotiable.
Yet as part of a comprehensive knee-jerk reaction to the FamFit proposal, leaders at Ramstein Air Force Base made reservations for some of their Recreation Specialists to attend WTU training at UPenn next Spring 2010. This is really an excellent example of exactly what is wrong with the current system. The Air Force is sending Recreation Specialists who, as described in Section III, don't have job descriptions which require fitness background, knowledge, or training. This should really raise serious red flags on its own, but compounding the quandary is that red cross volunteers described previously who hold comprehensive health certification backgrounds and have devoted hundreds of hours already (with the program still in its infancy) working with Soldiers at WTUs (see testimonials illustrating their impact) were completely left out of consideration for training. It is bordering on outrageous. And it pinpoints FamFit's core concern beautifully: up until now, where military family fitness is concerned, "band-aide solutions" which yield only cosmetic benefits have been used where a complete overhaul of existing program services is needed.
The solution is simple: employ Health Educators and Warrior Athlete Fitness Trainers following the suggested structure outlined in Encl 3. Current certified volunteers have an excellent chance to at least "make the list" of consideration for employment due to hundreds of hours of on the job training -- their volunteer work merits this opportunity. Implement a Quadrant of Care for WTU soldiers, integrate FamFit into the WTU, and involve family members and the community. This solution makes sense, is cost effective and has staying power.
Brig. Gen. Mike Tucker, the Army’s assistant surgeon general for warrior care and transition, remarked in early 2008: “I don’t want to create a generation of war fighters who will be panhandling 10 to 15 years from now because they have no life-skills"38. FamFit's integration into WTUs will help to eliminate complaints of Soldiers frustrated about lack of challenges in the WTU program. More importantly it will definitively show the government's commitment to its wounded Soldiers' rehabilitation and reintegration, and will in turn motivate Soldiers to invest more in their own recovery. Soldiers will consequently achieve success more quickly, more comprehensively, and more permanently.
BG Tucker's credo is “If it’s the business of healing and it’s not illegal, immoral or unethical, why aren’t we doing it? If it’s a regulation (in the way) let’s change it"41. Close integration of fitness and specifically FamFit into Soldiers' progressive healing process would radically facilitate all aspects of their recovery, and what's more... these Soldiers are hankering for the challenge.
