|Ahead of print publication
Pattern of injuries sustained during training: A retrospective record-based study
Vikas Maheshwari1, Neerav Porwal2, Rushikesh Gadhavi1, Arvind Kushwaha3, Arun Kumar Yadav4
1 Department of Neurosurgery, Command Hospital (SC), Pune, Maharashtra, India
2 Command Hospital (WC), Chandigarh, India
3 Department of Community Medicine, AIIMS, Nagpur, Maharashtra, India
4 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||07-Apr-2020|
|Date of Decision||25-May-2020|
|Date of Acceptance||04-Aug-2020|
|Date of Web Publication||01-Apr-2021|
Arun Kumar Yadav,
Department of Community Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Physical injuries constitute a major health problem in the training institutes. The present study was undertaken with the aim to analyze the injury pattern in a training institute. Materials and Methods: This study was carried out on male trainees of a premier training academy. Trainees with all forms of injuries were included in the study. This was a descriptive record-based study carried out at a tertiary-level hospital. The records were extracted from January 2011 to December 2016. These trainees were assessed in terms of their age, term, activity causing the injury, anatomical part injured, and their final disposal. Results: Out of a total of 5400 trainees, 1536 trainees with various forms of injuries were assessed (28.4%; 95% confidence interval [CI]: 27.2–29.7). Their mean age was 18.62 years (standard deviation: 0.9 years). The lower limbs were most commonly injured (n = 1167, 75.91%; 95% CI: 73.7%–78.0%). There were 865 (56.3%) cases of soft-tissue injuries in comparison to 671 (43.69%) cases of bony injuries. Injuries due to physical training outnumbered to those sustained during sporting activities. Majority of the cases were managed conservatively (n = 1445, 94.07%), and only 85 trainees required surgical intervention (5.53%). Loss of man-days ranged from 1 to 309 days (mean: 38.18 days). Conclusion: Injuries are an integral part of training, resulting in morbidity and loss of man-days. The descriptive epidemiology of the injuries may help in formulating preventive and promotive measures for injuries.
Keywords: Trainees, strength training, stress fracture
| Introduction|| |
The physical training imparts is imparted to improve physical prowess and a mental toughness of a trainees. This training is quite exacting and at times causes mild-to-severe injuries. The lower extremities (LEs) are the most vulnerable to injuries during activities such as running, route marches, and other physical exercises., These trainees undergo a rigorous basic training program spanning over 3 years at a premier training academy. During this period, activities are standardized with graded training schedule to increase their level of endurance.
This study was undertaken with the aim to analyze the injury pattern in these trainees so as to gain an insight into the causative factors and possible remedial measures to mitigate the injuries.
| Materials and Methods|| |
A retrospective record-based study was conducted at a tertiary-level hospital in western Maharashtra. It included trainees undergoing training at an academy, which has an intake of approximately 300 trainees per term twice in a year. The records of the students for the duration of 2010–2016 were taken. There were a total of 5400 trainees during this study period. The data were analyzed in terms of soft-tissue injuries such as contusion, strain, sprains, and various other bony injuries. It was also analyzed for term-wise distribution, causative mechanism, and the anatomical part inflicted. The data were collected from the emergency department, surgical outpatient department (OPD), and the in-hospital records of the admitted trainees.
Mean and standard deviation (SD) and frequency and percentage were used to describe quantitative and qualitative data, respectively. Contingency tables were made, and Chi-square test and its variant were used for statistical significance of association. Analysis of variance (ANOVA) or t-test was used for comparing quantitative data among the groups. Bonferroni's test was done for post hoc analysis. P < 0.05 was considered statistically significant. Data analysis was done using StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.
| Results|| |
The study population belonged to the age group ranging from 17 to 22 years, with a mean of 18.62 years (SD: 0.9). Out of a total of 5400 trainees, 1536 trainees with various forms of injuries were assessed during this study. This approximates to 28.4% (95% confidence interval [CI]: 27.2–29.7) incidence of injuries. They were all males because the training academy has an intake of male candidates only. The distribution of mode of injury, type, and treatment is depicted in [Table 1]. The mean body mass index (BMI) was 20.8 (SD: 1.2), and the term-wise BMI is shown in [Figure 1]. There was no statistical difference in terms for BMI (ANOVA test; P = 0.2).
The injuries sustained were maximum in the fourth term (n = 376, 24.47%), followed by third term (n = 299, 19.46%) and the least in the first term (n = 179, 11.6%) as shown in [Table 2] and [Figure 2]. These modes of injuries were not homogeneously distributed in the various terms. The majority of injuries sustained were during physical exercises, i.e., 850 cases (55.33%; 95% CI: 52.8–57.8), in comparison to sports injuries, which were 686 (44.67%; 95% CI: 42.2–47.2). Physical training (PT)/drills accounted for the highest subset of injuries in all the terms, as shown in [Table 2]. Injuries due to horse riding were common in the second term (10.81%). The further term-wise distribution of sports injuries is shown in [Table 2] and [Figure 3]. Anatomically, the lower limb injuries accounted for most of the injuries (n = 1166 injuries, 75.91%; 95% CI: 73.7%–78.0%) as compared to the upper limbs (n = 244 injuries, 15.8%; 95% CI: 14.1–17.8), which is shown in [Figure 4].
Soft-tissue injuries were more common (n = 865, 56.31%; 95% CI: 53.8–58.8) than the bony injuries (n = 671, 43.69%; 95% CI: 41.2–46.2). Of the soft-tissue injuries, contusions were more common (n = 511, 33.26%) than sprains/strains (n = 354, 23.04%). Among the bony injuries, stress fractures (SFs) were the most common (n = 469, 30.53%). The other fractures accounted for 13.15% (n = 202), as shown in [Table 1].
The soft-tissue and bony injuries were analyzed as per the age, BMI, term, and man-days lost, as depicted in [Table 3]. Bony injuries occurred were more common among younger cadets (P < 0.001) and among cadets with lower BMI (P < 0.02). Loss of man-days was more in bony injuries than soft-tissue injuries (P < 0.001).
Most of the injuries were managed with rest, brief hospital stays, or sick leave in few cases (n = 1445, 94.07%). Surgical intervention was required in 85 cases (5.53%), and six cases (0.39%) had out due to persistent disability. The man-days lost varied from as little as 1 day for minor injuries to 309 days for trainees with severe injuries (mean: 38.18, SD: 30.95, median [interquartile range (IQR)]), as shown in [Table 1].
| Discussion|| |
Highest levels of fitness is required by the trainees for prevention of injuries. This study included male trainees undergoing rigorous training at a premier training academy. The training period consists of six terms spanned over 3 years. These trainees undergo graded training with increasing level of physical activities as their term progresses.
The incidence of training-related injuries is more severe among trainees as compared to that of trained one. The reason for this is probably the unaccustomed physical stress that these ab initio trainees have to undertake.
Many studies both in India and abroad have been conducted on various aspects of injuries among trainees especially on recruits including studies on gender differentiation., However, literature search has shown that no Indian study has so far been done on trainees sustaining injuries during their training. This study included all aspects of physical injury including soft-tissue injury sustained during their training.
In the USA, training-related injuries are the leading cause of hospital admission/OPD management, and the cumulative risk of injury of the 8-week army basic training cycle was about 50% for women and 25% for men. This is quite comparable to our study, where the injury incidence was 28% in male trainees.
Our study showed that the maximal injuries were in the fourth and third terms. This is in little variance to the British Army officer cadets' study by Harwood et al., where 46% of the officer Trainees sustained injuries in their first term., This may be due to difference in training between the two countries, probably the training is more rigorous in the latter terms. The majority of injuries sustained were during PT (55.33%) in comparison to sports injuries (44.73%). Among the sports injuries, long-distance running was the most common modality of injury in trainees, which peaked in the fourth term (n = 61, 25.85%).
Anatomically, the LE accounted for most of the injuries during basic training (n = 1166 injuries, 75.24%), which is comparable to a British study conducted by Jones et al. Soft-tissue injuries (56.31%) were more common than bony injuries. Among the bony injuries, SFs were most common (30.53%). This again is quite comparable to a prospective study done at a training center among recruits in India, whereby that SF was the most common component of all injuries. A possible mechanism for SF is continuous remodeling and lack of adequate rest during intense PT.
In our study, most of the injuries were managed conservatively with adequate rest, a brief hospital stay, or sick leave in few cases. Surgical intervention was required in 85 cases (5.53%), and six cases (0.37%) were boarded out due to permanent disability. The man-days lost varied from as little as 1 day for minor injuries to 309 days for trainees with severe injuries (mean: 38.18, SD: 30.95, median IQR: 32 [24–47]).
Various risk factors for injury in the trainees have been identified. These include poor nutrition, low muscular strength, smoking, alcohol consumption, and any previous history of injury., Specific interventions that successfully reduce injuries without compromising training have been successfully tested.,
Our study has certain limitations; first, it is a record-based study, and hence minor injuries for which cadets did not report would have missed. Second, the data on other parameters such as strenuous exercise or physical stress before injury could not be collected and analyzed for association.
Injuries are an integral part of any PT and more so in any structured training. Although the training schedules are scientifically designed with a graded escalation of physical stress, it is essential to integrate modified PT regimen with thrust on strength training. Other preventive approaches include educating about injuries and having a unit-based injury surveillance system. A good record keeping of injury surveillance along with other remedial measures such as a well-designed footwear and fortnightly rest is recommended to reduce the injury burden. A continuous monitoring and periodical evaluation of policies is also recommended. A prospective study is also recommended to delineate the risk factors and confirm the findings of the study.
| Conclusion|| |
Injuries results in morbidity and loss of man-days. The term distribution of the injuries and their determinants may help in formulating preventive and promotive measures. However, a well-designed cohort study is recommended to confirm the findings of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]