Visible Injuries, or Common Ones?

When rehabilitation of military personnel comes up, the first thing most people picture is a prosthesis. Sometimes a psychologist. But there is another category that does not look like an injury at all, and that is in all likelihood far larger than it is assumed to be: injuries to the back.

When I began working on opening a veterans' rehabilitation centre, it seemed sensible to look at the numbers. Ukrainian data on this is still thin, which makes the figures from NATO armies worth attention. They have been collecting statistics on non-combat musculoskeletal injuries for decades, and those studies fill volumes: how many days a person is unfit for duty, how many such people there are in a unit, what it costs the budget. Non-combat musculoskeletal injuries account for close to sixty per cent of all limited duty days.

The reason they have this data is fairly simple. In their system, a damaged back creates an event. The person is taken off tasks, downgraded, discharged. Each of those steps is recorded somewhere, and twenty years later somebody is holding a statistic.

Here, a person with a disc protrusion or a hernia is usually not released, because there is nobody to replace them. They stay in service with something that hurts, until something happens that can no longer be ignored.

So the difference between us and them is not that we have less of it. It is that in their system it gets noticed, and in ours there is no mechanism for that.

Which also means that any figure we eventually arrive at will be an underestimate.

The numbers

Transferring their percentages onto us makes no sense: a different war, a different system, different rules. What can be looked at instead are the causes.

Weight. Body armour and a loaded pack, which together can exceed fifty kilograms. These are figures from foreign studies, but on this point they match our own.

Time. Their data was gathered under rotation: a few months in, then out, then recovery. Here, rotation happens when there is somebody to replace you, not when it is due.

Evacuation. They move casualties by vehicle. Here it is often carried out on foot, by people bearing more than their own body weight, acquiring their own protrusions and hernias while saving somebody else's life.

Sleep. The dullest item on this list and, it appears, one of the most important: tissue repair happens during sleep. In a dugout there is none.

Working seated. Drone operators spend hours in one position, hunched, in the cold. This factor barely appears in the older studies, because there have not been wars before in which this many people fight sitting down.

Not one of these is milder here. Most of them are considerably worse.

Not noticeble

A back injury has no point of origin, no moment after which the person became someone else. There are two years during which they carried the weight because they had to, and then one morning they could not get up.

There is no photograph and no date, and the person appears to move like anybody else, although we have no idea what the real situation is. None of it draws attention.

There is a great deal of discussion at the moment about how to sustain public support for defence spending over the years ahead. That support does not rest on campaigns. It rests on whether people can see that the state pays for the consequences. A veteran with a hernia often sees neither support nor payment, and draws conclusions from that which nobody later enjoys.

What’s next

Whether anything at all can be done right now is a complicated question, given that there are more urgent priorities.

But my aim is to raise it, so that it stops being the private business of those in pain and gradually becomes a subject of professional and public discussion, and in time moves to resolution at institutional level.

It is also worth remembering that the earlier a person reaches rehabilitation, the greater the chance they return, and the less it costs. The most expensive scenario is the one in which somebody endures it for two years and then can no longer come back, however sincerely they want to.

And one last point, which concerns not medicine but wording. As long as back injuries remain dissolved inside the general word "rehabilitation", they will lose out to everything that looks more acute. No system allocates resources to something it has no separate line for. That is probably the only thing here that can be shifted without money: setting the field apart as its own.

I am building a rehabilitation centre that will deal with exactly these cases, so I have my own stake in this subject. The sources I rely on are published, and the links are below.

Sources

1. Military Medicine, Oxford Academic. Burden of Musculoskeletal Injuries in U.S. Active Duty Service Members: A 12-Year Study Spanning Fiscal Years 2010–2021 https://academic.oup.com/milmed/article/189/Supplement_4/1/7906349

2. Military Medicine, Oxford Academic. Musculoskeletal Injuries and United States Army Readiness Part Ihttps://academic.oup.com/milmed/article/185/9-10/e1461/5805225

3. The Spine Journal. Spine-area pain in military personnel: a review of epidemiology, etiology, diagnosis, and treatmenthttps://www.sciencedirect.com/science/article/abs/pii/S1529943011013283