Introduction
The role of the medical branch in the selection of all military personnel is of utmost importance as all the selected candidates after clearing the minimum physical benchmarks also need to be declared as medically fit and mentally sound as per the parameters of all the concerned medical specialists. The purpose of this is to ensure that all the trainees, including the officer cadets, who have been cleared to join the training centres or academies are fit enough to withstand and cope with their respective rigorous training schedules and hectic curriculum to ensure minimum wastage or drop-outs;
Further and more importantly, during military service, all the successful trainees, especially officers, are able to lead a life of good and stable health besides high medical fitness to enable an optimum output or performance of their military duties both in peace and operational areas and also achieve the minimum morbidity rates.
It is my personal observation that there is a serious shortcoming or lacuna in our training system, especially in our military academies and some regimental training centres, where the professional advice and guidance of the dedicated medical authorities is either not being sought or optimally utilised, resulting in an avoidable higher wastage and morbidity rate of trainees, especially NDA cadets.
It is my firm belief that this is basically on account of lack of professional knowledge of the trainers in the science of physical education, medical science and sports injuries. Thus, the imparting of this vital knowledge by the concerned dedicated physical education and medical staff, especially qualified PT instructors and Sports Medicine staff, to all trainers, supervisory and directing staff would pay handsome dividends by way of lowering injuries, especially those which are stress-related, and drastically cut down the overall wastage including morbidity rate during training.
Medical Cover, Advice & Guidance during Training at the Military Academies
The role of medical authorities like MH Khadakwasla, MH Chennai, MH Dehradun in sustaining injury-free and healthy training of cadets of the NDA, OTA and IMA respectively need to be appreciated and enhanced for giving a special care and attention to all the cadets of these prestigious military academies.
The NDA, Khadakwasla, is the only training academy which has an MH co-located in its own campus besides an excellent additional back-up and support for all aspects of academics, physical education, sports and medical sciences from renowned hospitals and elite institutions like MH Kirkee, CH (SC), MH CTC, AFMC, AIPT (ASPT) and ASI & AFSMC in and around the Pune city. Hence, logically the drop-out or wastage rates of the NDA cadets, especially of medical cases and stress injuries, should be the lowest in comparison with other academies.
However, the past records of such cases would reveal that their cases have been far higher and the prime reason has been the non-acceptance or flouting of professional medical advice and guidance (from dedicated medical staff in its campus) by the senior cadets and trainers at the behest of the supervisory and directing staff in the Squadrons/Battalions of these cadets, besides their lack of professional knowledge or even awareness of the principles of physical training, medical science and their allied subjects.
Science Behind Stress Injuries
The scientific approach to sports and all forms of physical training dates back to the era before Christ when the ancient Greek physicians planned the training regimen and diet of the Olympic competitors. In that era, the Greek physician Galen wrote 87 detailed essays on nutrition, aerobic fitness and the strengthening of muscles. Stress fractures are one of the most common, potentially serious and overuse injuries.
Stress fractures mainly occur in weight-bearing bones, especially the shin/tibia. Cases of stress fracture of fibula, metatarsals and the neck of femur are also seen in the military training environment. Although the human body is continually remodelling the skeleton system based on the stresses received, there is a finite limit to the amount it can adapt, thus resulting in stress fractures which occur in the early stages of bone remodelling when the re-absorbtion of bone is outstripped by the development of the new bone.
Risk Factors for Stress Fractures
The risk factors for stress fractures which are particularly relevant and pertinent in any military training environments, especially academies like the NDA, IMA and OTA are (a) Sudden increase in frequency, intensity or duration of training (b) Training while in a state of exhaustion (c) Poor training techniques (d) Running activities on hard surface transmitting more force to muscles and bones (e) Restrictive diets or missing meals resulting in negative effect on bone density (f) Muscular weakness or muscle imbalances (g) Poor quality footwear.
Training & Prevention
Records and results of the training schedules with varying frequency, intensity and duration conducted for a Cross-Country Run of 12.5 km distance for the NDA cadets from Spring Term 2011 to Spring Term 2014 proved decisively the decrease in the incidences of stress fracture cases, especially when the distance was increased gradually.
Some of the positive indicators for adherence during training which will surely reduce the percentage of stress fractures and related injuries are: (a) Increase distance, frequency or intensity gradually over a period of time with a maximum of 10% increase per week to achieve the target (b) Focus on the quality of training not just quantity (c) Ensure an adequate recovery period between rigorous weight-bearing training activities to enable the body to heal, recover and recuperate (d) Do not train when exhausted as this leads to a higher levels of injuries (e) Adequate intake of calcium with 1300mg per day for all trainees.
Recovery, Rest & Recuperation: Post-Stress Fracture Occurrence
Once the stress fracture cases have been medically diagnosed, it is imperative that proper medical treatment and care is rendered to such cases to enable their speedy recovery with minimum loss to their training period. Although the time frame for recovery in the lower limb stress fractures is 8–17 weeks, it should be ensured that the return to normal activity too should be gradual and slow especially for weight-bearing exercises and runs, which should be resumed only with light walking after the pain has completely subsided. Cross-training can enable a speedy recovery.
Hence, non-weight bearing activities like swimming and cycling are recommended besides a continuation of the upper body exercises. Physiotherapy with all the latest technologies and treatments should be used optimally to facilitate a faster recovery of the trainees. Medications of any form should not be consumed without proper medical advice and guidance. Medicines which mask pain or inhibit bone healing should never be used excessively. Last but not the least, do not ignore stress fracture of any kind and be aware and sensitive to their causes and look out for early signs or indications.
Pilot Study by MH Khadakwasla (NDA)
The pilot study undertaken by MH Khadakwasla during 2011–14 (with a back-up from AFMC, Pune and AFSMC, Ghorpuri) to ascertain the spatial relationship between ‘stress related injuries’ and various contributing factors led to a considerable decline in morbidity, especially for training ailments, for the NDA cadets.
Besides this initiative, the hospital also managed to enhance the ‘nutritional status’ of the cadets and with some bold initiatives also brought down the ‘morbidity’ rate of cadets in the cases of ‘chicken pox’, ‘conjunctivitis’, pneumonia’, ‘stress fracture’ and ‘local skin infection’.
This goes on to prove beyond any doubt that efforts and initiatives such as these will surely pay handsome dividends and as such should be emulated by all the medical authorities, especially those in charge of medical cover, advice and guidance for the military training academies and regimental training centres, where the trainees or cadets are susceptible to these typical physical injuries and medical ailments.
Conclusion
The role of the medical authorities in the selection, training and maintenance of the medical fitness of all the military personnel is of paramount importance. It is highly unfortunate and regrettable that the professional medical advice, guidance and cover are not being utilised optimally for the benefit of the military trainees, especially the cadets for whom this is exclusively dedicated; The classic example being the NDA,which has everything on a platter. Positive steps are often taken at the behest of knowledgeable, dedicated, concerned and caring officers at the helm.
This temporarily changes wrong trends and brings down morbidity rates, reduces suffering and disability of trainees and leads to a better health and medical fitness of the cadets. On such rare occasions, the loss of precious training hours is minimised with fewer relegations, withdrawals and resignations. The morbidity rate of the cadets of all military academies is far higher than that of the military recruits.
This rate for the NDA cadets has always been traditionally higher than that of the other academies. This is a matter of deep concern and positive and permanent steps need to be taken in the right direction rather than taking false pride in this so-called tradition. Stress fractures and related medical cases/injuries are the single biggest factor for higher relegations and withdrawals in the military academies, especially the NDA.
Awareness of this article and following all that has been written both in letter and spirit will surely reduce the stress fractures and morbidity rates and result in a better health and overall fitness of the trainees, especially cadets.
Responses
Lt Gen R. S. Sujlana (Retd)
I endorse the views expressed in this article on the necessity of advice and guidance of a sports medicine specialist (SMS) at the training academies. I experienced the positive impact of an SMS (initially with Col Ghai and then Col Das Sarma) at the IMA when I was the Commandant. While the Army hospitals are always there for assistance but I recommend that an SMS must be on the posted strength of the Academy to ensure his presence at the most vital time i.e. PT and Games and other physical activity.
He should always be available to the local Army Hospital in a time frame of say, 1000 hrs to 1300 hrs, but his main role should be at the Academy. The Section/Military Hospital at the Academy must have a full-fledged Physiotherapy Deptt with the latest modern gadgets and well-trained physiotherapists. At the OTA, it may be necessary to have a lady physiotherapist also.
Physical training has to be and is done in a graduated manner (but then aberrations do take place). At the IMA soft tracks exist for running, rather even drill is initially started and continues for three months on soft ground. A regular interaction between the Platoon Commanders, SMS, and PT staff must take place.
The weak cadets must be identified for specifics (i.e. Strength, Agility or Endurance) and then the particular muscles/component should be addressed. In one course I remember that the SMS (Col Ghai) joined and gave expert advice and training, with the result that, out of the 27 GCs relegated, 21 became fit in a short time and passed all the physicals required.
Col C.M. Chavan (Retd)
The views expressed by Col Vinay Dalvi are very pertinent, as the same have the backing of the records as well as endorsement from the medical authorities. The importance of the same can be visualised that as far back as the Greek era, the scientific approach towards sports activities was adopted.
We are in the era when even shoes are designed specifically for an individual as every human being has a different style of running wherein the distribution of the weight of the body is displaced differently on the skeleton and muscles. The capability of every individual, though physically fit, is different for various activities. Hence is the importance of Rest, Recovery and Recuperation.
There is a need to address this issue seriously. It also must be realised that apart from injury, the cadet undergoes a tremendous amount of humiliation and frustration when he is not able to cope up with rest of the cadets. Keeping this in mind, the physical training has to be gradual and scientific.
Coming to sports medicine, there are very few takers in the AMC for specialising in this field. Hence, there is a need for the AMC top brass to ensure that this specialty gets equal importance. It is of utmost importance to ensure that physical training in all academies is carried out under the guidance of medical authorities. The trainers of all the academies need to undergo a sports medicine capsule to understand the importance of scientific training.
Lt Col Mrinal Kumar Gupta Ray (Retd)
I totally agree to the invaluable service that an intimate medical care may bestow on the budding soldiers, be it an officer trainee or a recruit. In fact, there are various categories to be taken care of or to be careful about:
- NDA cadets are in late teens or barely crossed teens, and mostly are at a tender age.
- Recruits are also at almost same age but with a tougher health background.
- Direct entry cadets are senior in age and would bear a developed and tougher body.
However, there can be exceptions to this rule. Thus, medical care and training must be graduated accordingly. Proper medical care and training to the training staff to treat the cadets should be with a constructive angle of training and not just plain ‘Ragra’, which will not only reduce the stress effect but also develop confidence in the minds of the candidates.
Excessive ‘Ragda’ by ‘ustads/seniors/DSs not only creates physical stress but also tends to develop a moral degradation when in order to avoid such unnecessary physical activities, the cadets try to take dubious means, which in later service reflects in their approach towards the regimental duties.
I would also suggest for the services of Psychologists or Counsellors to be made available for extreme or befitting cases in order to enable the needy cadets or recruits to confide in somebody considerate and helpful. In any case, the SSB/DIPR Psychologist or Technical Officer plays a crucial part in the selection of officer cadets and the psyche of these cadets can be best analysed with an objective comparison with the SSB selection profile or personality by such qualified persons only.
Lt Cdr Naveenkumar R. Kolli (Retd)
The necessity of professional medical advice and guidance is imperative in the military training institutes as it involves strenuous physical activities. My response to this very important article by Col Vinay B. Dalvi is based on two events during my training at the Naval Academy.
On the day my course joined the academy, trials were being conducted for a football team selection and one of my coursemates was selected to undergo training for the football team. The senior cadet in-charge of the team made this new entrant undergo the same rigorous training as that for the seasoned cadets of the senior terms. This over-exertion took its toll on my coursemate and he suffered an internal injury in the knee which took a long time to heal and he had to miss most of the physical activities during the training.
In another instance, a coursemate of mine collapsed in the middle of a planned 14-km navigation run. No one including the directing staff realised the seriousness of the condition and our team carried the unconscious companion on a stretcher for the rest of the run instead of availing the services of the ambulance that was behind us. At the end of the run, everyone was shocked to know that his blood pressure was too low due to a severe heat stroke and dehydration from which he never recovered and died the next day in Hospital.
Later, during my tenure with an academic project for a weather forecaster course I learnt that heat stress is a vital aspect of physical training and Heat Index (effective heat due to combination of Temperature and Humidity) must be taken into consideration while planning any rigorous physical training. And the Heat Index at Goa during the months from April to June is very high and unsuitable for rigorous physical activities. Based on these two events, I would like to put forth the following suggestions regarding physical training at the Academies and Training Centres:
- Supervision by qualified personnel during training to avoid the ill-effects of over-exertion during training.
- Sensitisation of staff and senior cadets regarding the need of acclimatisation and gradual increase in the rigour of training to the new trainees.
- Effects of Heat Index must be considered while planning for rigorous physical activities; care and precautions must be taken to mitigate the effects of heat stress.
- Staff and cadets must be provided training to assess the basic condition of someone who has sustained injuries or fallen ill while training and they must also be sensitised to seek medical supervision when they are not sure of the condition.
Dr Dhananjay More
I have a few suggestions: The authorities should publish the exact nature (details of the actual activities) of physical training which a candidate has to undergo during his/her training period, just like the subjects are published before the theory exam. This will provide some time for the candidates to prepare themselves for the physical training. It will go a long way to avoid serious, near-fatal injuries during the actual training.
Irrespective of that, a full-fledged Fitness Test should be carried out for every candidate before he/she starts the physical training. This will help the authorities to categorise candidates into different groups as per their fitness levels and then determine the optimum training intensity for each group for a safe and effective training programme.
A special training programme should be designed for candidates with orthopaedic limitations, hypertension, obesity etc. For this purpose, a Medical Professional with a background in Sports Medicine can be immensely helpful.
(This article first appeared in the book 'A Campaign Called Victory India' by Colonel Vinay B Dalvi (Retd) and published by Pentagon Press LLP. The essay has been reproduced as part of Mission Victory India's online archival efforts)
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