I recently had the privilege of providing physiotherapy support to 30 competitors, both current and ex-serving ADF members, during the Warrior Games in Orlando, Florida. The games are similar to the Invictus Games, where wounded, injured, and ill active military and veteran members compete in adaptive sports as part of their recovery and rehabilitation. Team Australia was invited to participate alongside US SOCOM, US Air Force, US Army, US Navy, and the Marines in eleven different adaptive sports.
Wheelchair rugby, wheelchair basketball, seated volleyball, track, field, swimming, powerlifting, archery, cycling, and indoor rowing events were spread over an intensive ten-day period. Competitors were accompanied by their family and friends, who were treated to a once in a lifetime opportunity of exclusive access to Disney World amongst other amazing perks. The intent of the games is to provide an opportunity for individuals and their families to continue to recover and rehabilitate from life changing injuries and illnesses. The ADF also stands to benefit from the lessons learnt from these types of competitions. These are my reflections on how we might translate those lessons into a Defence context. As the Chief of Army LTGEN Simon Stuart stated in a recent letter to Army reflecting on the Royal Commission into Defence and Veterans Suicide “The opportunity exists today, and we must act on it today.”
Background
Having spent the last four years in Army in predominantly non-clinical roles in human performance, injury prevention and HQ positions, I approached this sports trip with a fresh healthcare lens. The traditional view of what sports physiotherapy offers such as courtside support, strapping, and acute injury assessment and management, while our bread and butter, is only a small element of a physiotherapist’s skillset. Similar to the workload on deployment, in the field, or even in garrison, management of acute injuries is probably only 10% of what a physiotherapist does. We possess the training and qualifications to also be integral to reducing injury risk and preventing injuries in a holistic manner. To do this effectively, physiotherapists must be involved in the training and preparation phases (of sport or work), to consider and advise on load management, nutrition, recovery, early intervention, and ongoing rehabilitation programs.
Reflection one – Holistic and multi-disciplinary care
Medical staff for the Warrior Games included a team doctor and psychologist, as well as physiotherapy. The team was fortunate to also have CAPT Brian Heilbronn as their strength and conditioning coach. Brian is an accredited exercise physiologist (EP) and was invaluable in contributing to monitoring of training loads in the lead up to the games and assisting with active recovery during the tournament. Having this multi-disciplinary, collaborative approach to physical health inclusive of a doctor, psychologist, physiotherapy, and exercise physiology greatly enhanced the experience for the team and kept injuries to a minimum.
Good nutrition is a critical factor in injury prevention, so in the absence of a sports dietitian or nutritionist, evidence-based information on optimal fuelling for sports and recovery was provided by the existing health support team during the training camp as well as advice during travel to logistics staff on provisioning of food.
Translation: EPs and sports dietitians are invaluable skill sets for the military and should be seen as force multipliers to the ADF. Not only would these professions contribute to improving the health literacy of members, but critically, at a systems level, they could provide subject matter expertise on training, programming, and even contracting (like provision of food at messes for example). While there are a handful of people within the ADF with EP and dietetics qualifications, there are not formal positions on the gazette and subsequently these skills are only used in ad hoc situations.
I’ve long been an advocate for EPs in Army, to bring additional skills and manpower to PTIs and physios to monitor and enhance the physical health and performance of our soldiers. The biggest gap in the health and performance continuum, in my opinion, is in early intervention. These strategies are used in the early injury stages to limit injury progression. Physios generally do not get to see members until after they are injured, when prevention is too late. Many injuries in Defence are associated with exercise and physical training. While PTI’s are at the coal face, the system does not afford the ratios to individualise training to the point where we can monitor cumulative load sufficiently. Most injuries in Defence are not traumatic, but rather come on gradually. Even those that appear suddenly will be more ‘the straw that broke the camel’s back’, rather than truly traumatic. If we increase the manpower (for data capture, analysis and translation) towards understanding training loads, then we will be better placed to reduce injury risk – but it must be a collaborative approach. We don’t need to have an EP or dietitian for every unit but strategically placed to advise in performance health teams could have real impact to readiness levels.
Reflection two – a Biopsychosocial Model of health
In garrison, there is a tendency to be quite conservative in our management of musculoskeletal injuries. However, transfer to an intense sporting competition, with competitors rehabilitating with cancer, amputations, traumatic brain injuries, chronic regional pain syndrome, and recovering from severe traumatic accidents; the word conservative goes out the window. All 30 competitors are walking (in some cases rolling!) advertisements for the power of the mind and unequivocal proof that a biopsychosocial model of health is not just a theory but is indisputable fact. This model reflects current understanding of the complex nature of the human mind and body; that biological, psychological, and social factors exist together and cannot be uncoupled.
Translation: Best practice physical health support uses a biopsychosocial model of care. The addition of eight Joint Health Unit regional physiotherapy managers across the country in 2022 has greatly improved the ability of physiotherapy departments to have improved communication between Joint Health, across departments and to industries as well as professional development opportunities for all physios (contracted, APS, and military). There are exciting changes in JHC continuing to evolve, with increased interactions with the UK Department of Defence on topics such as women’s’ health, nutrition and best practice guidelines for clinical care. The overlap with the sports science community and international militaries, including leveraging the AIS and Australian Army strategic partnership supports a biopsychosocial model of health care.
Reflection three – Harnessing the power of sport for retention
The power of adaptive sports competitions to impact people’s recovery and rehabilitation journeys such as Invictus and Warrior games is backed by research, and having seen first-hand the determination, strength and resilience of these competitors, it begs the question; could we reframe how we classify and employ injured and ill members to keep them serving? Given the recruiting and retention issues faced by the ADF, this should be an appealing proposition to career management and senior leaders.
Warfare continues to evolve, as do the physical requirements of providing effective service along with it. While we still need the physically demanding roles of infantry, combat engineers, artillery, and armoured corps, and physically robust combat support staff like combat medics and military police – the premise that the rate of medical discharge reflects the number of members’ so physically or mentally broken they cannot get back to a fit state to serve seems dubious when standing on the sideline of any of the events in Orlando and witnessing the grit and determination these veterans and members who are transitioning have.
Translation: Review policy on medical downgrade timeframes. While medical discharges are complex and are all individual journeys, many start with being downgraded for a physical injury. Policy in the Defence Health Manual states that a member who requires restrictions for more than 28 days is to have a unit military employment classification review, and potentially be downgraded. The time to recover from a moderate musculoskeletal injury varies dependant on tissue type and many extrinsic and intrinsic factors, but even a common grade 2 muscle strain can take more than six weeks (42 days), with tendons/ ligaments and bones often taking a lot longer. In addition to healing time, we also need to afford appropriate time to achieve morphological adaptation of tissues – that is, improving strength and conditioning to a point the member is occupationally ready.
Aside from alleviating the administrative burden on healthcare staff that accompanies a downgrade, aligning the policy with current evidence on physiological healing times has the potential to also relieve the mental stress members may feel. Underreporting of injuries has been documented, and anecdotally I have seen many members attempt to push through fitness tests to avoid being downgraded. By giving members the appropriate time to recover, the benefit to mental health would be profound.
In conclusion, sport (able-bodied or adaptive) has the power to contribute to physical and mental resilience, team cohesion and a sense of belonging. These are all qualities the ADF seeks in its’ members, and the recent Warrior Games team should be immensely proud of what they achieved and how they represented the ADF. We owe it to past, present, and future ADF members to continue to improve the physical health support provided to every sailor, soldier, and aviator. Translating research, knowledge, and lessons learnt should not wait for official reports or explicit direction but be a continual process at all levels of the organisation.
Postscript: An example of the grit and determination of the competitors is CAPT Doug Griffiths, who is raising money for Invictus Australia, battling cancer, and competing in Kona in October.
