Post-Traumatic Osteoarthritis, Psychological Health, and Quality of Life After Lower Limb Injury in U.S. Service Members.

INTRODUCTION: The aims of this project were to assess (1) the prevalence and timing of post-traumatic osteoarthritis (PTOA) after a traumatic lower limb injury, (2) the risk of PTOA based on injury type, and (3) the association of PTOA with psychological health and quality of life (QoL). MATERIALS AND METHODS: The Wounded Warrior Recovery Project (WWRP) database and the Expeditionary Medical Encounters Dataset were queried to identify service members injured during deployment. The Military Health System Data Repository was utilized to extract medical record data to identify individuals with PTOA. Data on PTSD, depression symptoms, and QoL were extracted from the WWRP. RESULTS: Of the 2,061 WWRP participants with lower limb injuries, 124 (6%) were diagnosed with PTOA, with first PTOA diagnosis occurring 3.8 ± 3.1 years after injury. Of the injury categories identified, only fractures were associated with high odds of lower limb PTOA (adjusted odds ratio [OR] = 3.92, 95% confidence interval [CI]: 2.38, 6.44). Individuals with PTOA diagnoses reported lower QoL scores relative to those without PTOA (F(1,2057) = 14.21, B = -0.05, P < .05). Additionally, rates of PTSD and depression symptoms were high but not different between those with or without PTOA. CONCLUSIONS: Despite a low prevalence of lower limb PTOA in our study, fractures increased the risk of PTOA after deployment-related injuries. Additionally, those with PTOA reported lower QoL scores relative to those without PTOA. The findings of this study highlight the personalized needs of patients with trauma beyond just the repair of the immediate injury.

Associations between health-related behaviors and self-reported cognitive symptoms in U.S. military personnel injured on deployment.

Health behaviors may be core contributors to cognition and mental health following mild traumatic brain injury (TBI). The aims of the present study examined: (1) whether health behaviors including sleep duration, alcohol use, and physical activity differed in injured military personnel with and without deployment-related mild TBI history and (2) the relative contributions of health behaviors and deployment-related mild TBI history to self-reported cognitive, posttraumatic stress disorder (PTSD), and depressive symptoms. Participants included 3076 military personnel injured on deployment participating in the Wounded Warrior Recovery Project, an ongoing web-based study. Military personnel with deployment-related mild TBI history reported similar rates of physical activity and levels of alcohol problems as those without, but were less likely to report receiving the recommended duration of sleep. When adjusting for demographic and injury variables, all three health behaviors were associated with cognitive, PTSD, and depressive symptoms. Alcohol problems demonstrated significant but small effects across all outcomes measures (ηp2=.01) whereas physical activity was associated with slightly larger effects albeit still within the small range (ηp2=.02-0.04). Duration of sleep bordered a medium effect for cognitive symptoms (ηp2=.05) and was in the medium range for PTSD and depressive symptoms (ηp2=.06). Although deployment-related mild TBI history was significant in all models, effect sizes were small (ηp2=.01). Findings from the present study provide support that health behaviors have stronger effects with regard to cognitive, PTSD, and depressive symptoms compared to deployment-related mild TBI history in military personnel and, given their modifiable nature, may represent treatment targets in this population.

Deployment-related concussion and long-term health-related quality of life among US military personnel.

PURPOSE: To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel. METHODS: The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates. RESULTS: A lower PCS score was observed in participants with concussion with LOC (B = - 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B = - 4.84, p < 0.001; MCS: B = - 10.53, p < 0.001) and depression (PCS: B = - 2.85, p < 0.001; MCS: B = - 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL. CONCLUSION: Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.

Differences in quality-of-life scores across injury categories by mental health status among injured U.S. military service members and veterans.

PURPOSE: Posttraumatic stress disorder (PTSD) and depression are strong predictors of poor health-related quality of life (HRQOL) among injured U.S. military service members (SMs). Patterns of HRQOL between injury categories and injury categories stratified by mental health (MH) symptoms have not been examined. Among deployment-injured SMs and veterans (n = 4353), we examined HRQOL and screening data for PTSD and/or depression within specific injury categories. METHODS: Participants included those enrolled in the Wounded Warrior Recovery Project with complete data for HRQOL (SF-36) from June 2017 to May 2020. Injuries were categorized using the Barell Injury Diagnosis Matrix (Barell Matrix). Mean physical component summary (PCS) and mental component summary (MCS) scores were calculated for each injury category and stratified by the presence or absence of probable PTSD and/or depression. RESULTS: The average follow-up time that participants were surveyed after injury was 10.7 years. Most participants were male, non-Hispanic White, served in the Army, and enlisted rank. Mechanism of injury for 77% was blast-related. Mean PCS and MCS scores across the entire sample were 43.6 (SD = 10.3) and 39.5 (SD = 13.3), respectively; 50% screened positive for depression and/or PTSD. PCS and MCS scores were significantly lower within each injury category among individuals with probable PTSD and/or depression than those without. CONCLUSION: Among deployment-injured SMs, those with probable PTSD and/or depression reported significantly lower HRQOL within injury categories and HRQOL component (i.e., physical or mental) than those without. Findings are consistent with prior reports showing mental health symptoms to be strongly associated with lower HRQOL and suggest integration of mental health treatment into standard care practices to improve long-term HRQOL.

Post-Combat-Injury Opioid Prescription and Alcohol Use Disorder in the Military.

INTRODUCTION: Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers. METHODS: Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021. RESULTS: Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis. CONCLUSIONS: The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids.

Psychological comorbidity: Predictors of residential treatment response among U.S. service members with posttraumatic stress disorder.

Residential posttraumatic stress disorder (PTSD) research in military samples generally shows that in aggregate, PTSD symptoms significantly improve over the course of treatment but can remain at elevated levels following treatment. Identifying individuals who respond to residential treatment versus those who do not, including those who worsen, is critical given the extensive resources required for such programs. This study examined predictors of treatment response among 282 male service members who received treatment in a U.S. Department of Defense residential PTSD program. Using established criteria, service members were classified as improved, indeterminate (referent), or worsened in terms of self-reported PTSD symptoms. Multinomial logistic regression results showed that for PTSD symptoms, higher levels of pretreatment PTSD symptom severity were associated with significantly lower odds of being in the improved group, adjusted odds ratio (aOR) = 0.955, p = .018. In addition, service members who completed treatment were significantly more likely to be in the improved group, aOR = 2.488, p = .048. Longer average pretreatment nightly sleep duration, aOR = 1.157, p = .035, and more severe pretreatment depressive symptoms, aOR = 1.109, p = .014, were associated with significantly higher odds of being in the improved group. These findings reveal clinical characteristics better suited for residential PTSD treatment and highlight implications for comorbid conditions.

Prevalence and correlates of self-reported cognitive difficulties in deployment-injured U.S. military personnel.

Cognitive difficulties typically resolve within days to weeks following mild traumatic brain injury (mTBI); however, a sizable proportion of individuals continue to report cognitive symptoms months to years later that are often associated with posttraumatic stress disorder (PTSD) and depression to a greater degree than a history of mTBI. The current study sought to evaluate the prevalence of self-reported cognitive difficulties as well as the relative contributions of demographic, injury-related, and mental health variables in a large study of U.S. military personnel injured during deployment since 2001. Slightly fewer than half (42.0%) of participants reported elevated cognitive difficulties compared with a normative population; however, this was driven primarily by those who screened positive for PTSD or depression. Hierarchical linear regression revealed that various demographic and injury factors, including lower educational attainment, retired or separated military status, enlisted rank, and a history of deployment-related mTBI, were associated with more self-reported cognitive difficulties, f2 = 0.07. Screening positive for PTSD or depression accounted for 32.1% of the variance in self-reported cognitive symptoms, f2 = 0.63, whereas injury variables, including a history of deployment-related mTBI, albeit significant in the model, accounted for 1.6%. The current findings add to the growing body of literature underscoring the importance of screening for and treating mental health conditions in injured military personnel.

Prospective Evaluation of Health Outcomes in a Nationwide Sample of Aeromedical Evacuation Casualties: Methods From a Pilot Study.

INTRODUCTION: Although retrospective analyses have found that combat-injured service members are at high risk for mental and physical health outcomes following injury, relatively little is known about the long-term health of injured service members. To better understand long-term health outcomes after combat injury, a large, prospective observational cohort collecting both subjective and objective health data is needed. Given that a study of this nature would be costly and face many logistical challenges, we first conducted a pilot to assess the feasibility of a larger, definitive study. MATERIALS AND METHODS: We ran a prospective, observational pilot study of 119 combat-injured service members and veterans who completed (1) at least one set of laboratory measurements (blood and urine sample collection and vitals measurements) at Clinical Laboratory Improvement Amendment of 1988 compliant laboratory locations and (2) at least one online assessment for the Wounded Warrior Recovery Project (WWRP), a 15-year examination of patient-reported outcomes among service members injured on combat deployment. We recruited the pilot study cohort from WWRP participants who met eligibility criteria and indicated interest in additional research opportunities. We collected laboratory values and patient-reported outcomes at baseline and again 1 year later, and obtained demographic, injury, and military service data from the Expeditionary Medical Encounter Database. The David Grant USAF Medical Center Institution Review Board (IRB) and the Naval Health Research Center IRB reviewed and approved the study protocols. RESULTS: During recruitment for the pilot study, 624 study candidates were identified from WWRP. Of the 397 candidates we contacted about the pilot study, 179 (45.1%) enrolled and 119 (66.4%) of those who enrolled completed the first year of participation. The second study year was suspended due to the coronavirus disease-2019 pandemic. At the time of suspension, 72 (60.5%) participants completed follow-up laboratory appointments, and 111 (93.3%) completed second-year WWRP assessments. Participants in the pilot study were predominately male (95.0%) and non-Hispanic White (55.5%), with a median (interquartile range) age of 38.3 (34.1-45.4) years. CONCLUSIONS: Collection of patient-reported outcomes and laboratory samples in a geographically dispersed cohort of combat-injured service members is possible. While significant challenges exist, our pilot study results indicate that a larger, longitudinal, cohort study is feasible.

Prosthesis satisfaction and quality of life in US service members with combat-related major lower-limb amputation.

BACKGROUND: Military amputee patient care programs offer extensive services, including advanced prosthetic devices, to restore function and improve quality of life (QOL) among veterans and service members with combat-related limb loss, but research on satisfaction with these devices is limited. OBJECTIVE: To assess prosthesis satisfaction and QOL in US service members and veterans with combat-related major lower-limb amputation. STUDY DESIGN: Cross-sectional study. METHODS: Eighty-six participants with combat-related major lower-limb amputation completed the Orthotics and Prosthetics Users' Survey (OPUS) Satisfaction with Device scale and Quality of Well-Being Scale, Self-Administered, for the Wounded Warrior Recovery Project. RESULTS: Most participants (62%-88%) responded Agree or Strongly Agree to OPUS Satisfaction with Device items on the fit, weight, comfort, ease of donning, appearance, and durability of their prosthesis. By contrast, the majority of participants (55%-79%) responded Disagree or Strongly Disagree to items on clothes being free of wear and tear, skin free of abrasions and irritations, and the affordability of their prosthesis. In linear regression analysis, total OPUS Satisfaction with Device score was positively associated with Quality of Well-Being Scale, Self-Administered score (ß = 0.0058; P = 0.004). CONCLUSIONS: Findings indicate the majority of participants were satisfied with the overall functionality of their prosthesis, but dissatisfied with the effect of their prosthesis on clothing and skin, as well as expenses related to their prosthesis. Additionally, prosthesis satisfaction was positively associated with QOL.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation.

PURPOSE: Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes. MATERIALS AND METHODS: Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status. RESULTS: Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning. CONCLUSIONS: Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

Mental and physical health, and long-term quality of life among service members injured on deployment.

BACKGROUND: More than 52,000 casualties have been documented in post-9/11 conflicts. Service members with extremity injuries (EIs) or traumatic brain injury (TBI) may be at particular risk for long-term deficits in mental and physical health functioning compared with service members with other injuries. METHODS: The present study combined medical records with patient reports of mental health and health-related quality of life (HRQOL) for 2,537 service members injured in overseas contingency operations who participated in the Wounded Warrior Recovery Project. Combined parallel-serial mediation models were tested to examine the pathways through which injury is related to mental and physical health conditions, and long-term HRQOL. RESULTS: Results revealed that injury was indirectly related to long-term HRQOL via its associations with physical health complications and mental health symptoms. Relative to TBI, EI was associated with a higher likelihood for a postinjury diagnosis for a musculoskeletal condition, which were related to lower levels of later posttraumatic stress disorder (PTSD) symptoms, and higher levels of physical and mental HRQOL. Similarly, EI was related to a lower likelihood for a postinjury PTSD diagnosis, and lower levels of subsequent PTSD symptoms, and therefore higher physical and mental HRQOL relative to those with TBI. Despite this, the prevalence of probable PTSD among those with EI was high (35%). Implications for intervention, rehabilitation, and future research are discussed.

Trajectory of self-rated health after combat-related injury.

BACKGROUND: The U.S. military conflicts in Iraq and Afghanistan yielded the most combat casualties since Vietnam. With more service members than ever surviving their wounds, prospective research on factors related to long-term, patient-reported outcomes, including self-rated health (SRH), has increased importance. This study's objective was to use preinjury and postinjury SRH measures to identify trajectories and predictors of SRH after combat-related injury. METHODS: The Wounded Warrior Recovery Project was queried for U.S. military personnel with combat-related injuries from Iraq or Afghanistan between 2004 and 2011. A single-item measure was used to assess SRH once prior to injury and twice after injury, and responses included excellent, very good, good, fair, or poor. Only those with good or better preinjury SRH levels were included. SRH trajectories were identified and defined. Multinomial logistic regression examined the association between injury-specific characteristics, post-traumatic stress disorder (PTSD), and SRH trajectory. RESULTS: The study sample included 1,093 military personnel. Overall, 4 SRH trajectories were identified: (1) 56.7% resilient (preinjury SRH level was maintained throughout follow-up), (2) 9.4% recovered (SRH declined on first postinjury measure then returned to preinjury level), (3) 22.9% delayed (SRH declined only on second postinjury measure), and (4) 11.0% chronic (SRH declined on first postinjury measure and did not return to preinjury level). In multinomial logistic regression and relative to the resilient group, screening PTSD positive, serious-severe injury severity, and lower extremity injury predicted membership in the recovered and chronic groups, whereas back injury predicted membership in the chronic group only. CONCLUSION: This is the first study to examine long-term SRH trajectory following combat-related injury, finding that a majority of military personnel remain at their preinjury health levels of good or better. Decreases in postinjury SRH were associated with physical and psychological factors, which reinforces the need for a multidisciplinary approach to care.

Symptom profiles following combat injury and long-term quality of life: a latent class analysis.

PURPOSE: The purpose of this study was to identify symptom profiles among U.S. military personnel within 1 year after combat injury and assess the relationship between the symptom profiles and long-term quality of life (QoL). METHODS: The study sample consisted of 885 military personnel from the Expeditionary Medical Encounter Database who completed (1) a Post-Deployment Health Assessment (PDHA) within 1 year following combat injury in Iraq or Afghanistan, and (2) a survey for the Wounded Warrior Recovery Project (WWRP), a longitudinal study tracking patient-reported outcomes (e.g., QoL) in injured military personnel. Fifteen self-reported symptoms from the PDHA were assessed using latent class analysis to develop symptom profiles. Multivariable linear regression assessed the predictive effect of symptom profiles on QoL using the physical (PCS) and mental (MCS) component summary scores from the 36-Item Short Form Survey included in the WWRP. Time between PDHA and WWRP survey ranged from 4.3 to 10.5 years (M = 6.6, SD = 1.3). RESULTS: Five distinct symptom profiles were identified: low morbidity (50.4%), multimorbidity (15.6%), musculoskeletal (14.0%), psycho-cognitive (11.1%), and auditory (8.9%). Relative to low morbidity, the multimorbidity (ß = - 5.45, p < 0.001) and musculoskeletal (ß = - 4.23, p < 0.001) profiles were associated with lower PCS, while the multimorbidity (ß = - 4.25, p = 0.002) and psycho-cognitive (ß = - 3.02, p = 0.042) profiles were associated with lower MCS. CONCLUSION: Multimorbidity, musculoskeletal, and psycho-cognitive symptom profiles were the strongest predictors of lower QoL. These profiles can be employed during screening to identify at-risk service members and assist with long-term clinical planning, while factoring in patient-specific impairments and preferences.

The Relationships Between Self-reported Pain Intensity, Pain Interference, and Quality of Life Among Injured U.S. Service Members With and Without Low Back Pain.

Low back pain is a prevalent military and veteran health problem and individuals injured on deployment may be at particularly high risk of pain conditions. Given that increasing numbers of active duty and veteran military personnel are seeking care in community settings, it is critical that health care providers are aware of military health issues. The current study examined the prevalence of low back pain among individuals with deployment-related injuries, compared their self-reported pain intensity and interference ratings, and assessed the relationship between low back pain, self-reported pain ratings, and quality of life. Almost half of participants had low back pain diagnoses, and individuals with low back pain reported significantly higher intensity and interference due to their pain than individuals without low back pain. Finally, the relationship between low back pain and quality of life was explained by self-reported pain indices, underscoring the importance of patient-centered metrics in pain treatment.

Overcoming Adversity and Stress Injury Support (OASIS): Evaluation of Residential Treatment Outcomes for U.S. Service Members with Posttraumatic Stress Disorder.

Research on residential posttraumatic stress disorder (PTSD) treatment has predominantly focused on the U.S. veteran population, whereas limited research exists regarding active duty service members. The present study evaluated outcomes among service members who received treatment in the Department of Defense's only residential PTSD program, Overcoming Adversity and Stress Injury Support (OASIS). Over a 5-year period, 289 male service members with combat-related PTSD received treatment in the program. Service members completed an initial assessment and weekly PTSD and depression self-report measures during the 10-week program. Multilevel modeling results demonstrated statistically significant reductions in PTSD. On average, participants reported a 0.76-point reduction on the PTSD Checklist, B = -0.76, p < .001, for each additional week of treatment. Pretreatment symptom scores and fitness-for-duty status predicted PTSD symptoms across time. Weekly changes in depression symptoms were not statistically significant; however, a significant Time × Pretreatment Depression Severity interaction emerged. Service members with higher baseline levels of depression severity showed larger reductions in depression symptom severity than those with lower levels, B = -0.02, p = .020, although a sizeable minority continued to retain symptoms at diagnostic levels. Depression symptom change was not related to any other treatment- or service-related variables. Differing trajectories were found between service members whose symptoms improved over the course of residential treatment and those who did not. The results indicate that there were larger improvements in PTSD than depression symptoms and highlight the need to optimize care provision for service members with severe PTSD or comorbid symptoms.

Persistent Opioid Use After Combat Injury and Subsequent Long-term Risk of Abuse: A Retrospective Cohort Study.

OBJECTIVE: To determine whether persistent opioid use after injury is associated with subsequent long-term development of clinically recognized opioid abuse. SUMMARY BACKGROUND DATA: Opioid abuse is an epidemic in the United States and trauma can initiate persistent use; however, it remains unclear whether persistent opioid use contributes to the subsequent development of opioid abuse. The care of combat casualties by the Departments of Defense and Veterans Affairs uniquely allows investigation of this long-term outcome. METHODS: This retrospective cohort study randomly selected 10,000 battle-injured United States military personnel. We excluded patients who died during initial hospitalization or within 180 days of discharge, had a preinjury opioid abuse diagnosis, or had missing data in a preselected variable. We defined persistent opioid use as filling an opioid prescription 3 to 6 months after discharge and recorded clinically recognized opioid abuse using relevant diagnosis codes. RESULTS: After exclusion, 9284 subjects were analyzed, 2167 (23.3%) of whom developed persistent opioid use. During a median follow-up time of 8 years, 631 (6.8%) patients developed clinically recognized opioid abuse with a median time to diagnosis of 3 years. Injury severity and discharge opioid prescription amount were associated with persistent opioid use after trauma. After adjusting for patient and injury-specific factors, persistent opioid use was associated with the long-term development of clinically recognized opioid abuse (adjusted hazard ratio, 2.39; 95% confidence interval, 1.99-2.86). CONCLUSIONS: Nearly a quarter of patients filled an opioid prescription 3 to 6 months after discharge, and this persistent use was associated with long-term development of opioid abuse.

Health Behaviors Among Service Members Injured on Deployment: A Study From the Wounded Warrior Recovery Project.

INTRODUCTION: Service members (SMs) who are injured on deployment are at risk for myriad long-term health problems that may be ancillary to their physical injury, including high rates of depression and posttraumatic stress disorder, and poor health behaviors (e.g., problem drinking, cigarette and tobacco use, poor sleep quality, and sedentary lifestyle). As the specific health behaviors injured SMs engage in have been largely ignored, the primary aim of this study was to compare health behavior patterns among those with and without mental health problems in a large, representative sample of SMs injured on combat deployment. MATERIALS AND METHODS: Participants (N = 3,303) completed behavioral health assessments between September 2018 and April 2019 as part of the Wounded Warrior Recovery Project. Multivariate linear regressions and binary logistic regressions were used to evaluate differences between mental health screening status and health behavior outcomes, adjusting for injury severity, age, and years since injury. RESULTS: Overall, about half of participants screened positive for posttraumatic stress disorder and/or depression (49%). Participants reported high rates of alcohol use and problems, cigarette and tobacco use, inadequate sleep and poor sleep quality, and low levels of physical activity. With the exception of number of drinking days and likelihood of current tobacco use, participants who screened positive for a mental health disorder evidenced significantly worse health behavior outcomes. CONCLUSIONS: The results provide a preliminary glance into the mental health and health behaviors of SMs roughly a decade after injury, and underscore the importance of examining the interplay between mental, physical, and behavioral health outcomes among wounded warriors to promote health and wellness.

Long-Term Outcomes of Service Women Injured on Combat Deployment.

Sex- and gender-based health disparities are well established and may be of particular concern for service women. Given that injured service members are at high risk of adverse mental and behavioral health outcomes, it is important to address any such disparities in this group, especially in regard to patient-reported outcomes, as much of the existing research has focused on objective medical records. The current study addressed physical and mental health-related quality of life, mental health symptoms, and health behaviors (i.e., alcohol use, sleep, and physical activity) among a sample of service women injured on deployment. Results indicate that about half of injured service women screened positive for a mental health condition, and also evidenced risky health behaviors including problematic drinking, poor sleep, and physical inactivity. Many of the mental and behavioral health variables demonstrated statistically significant associations with each other, supporting the relationships between psychological health and behaviors. Results provide additional evidence for the importance of access to integrated and effective mental healthcare treatment for injured service women and the need for screening in healthcare settings that address the multiple factors (e.g., mental health symptoms, alcohol use, poor sleep) that may lead to poor outcomes.

Prevalence of Low Back Pain and Relationship to Mental Health Symptoms and Quality of Life After a Deployment-related Lower Limb Amputation.

STUDY DESIGN: Retrospective, cross-sectional study. OBJECTIVE: To assess the prevalence and association of low back pain (LBP) with psychosocial factors in Service members with amputations. SUMMARY OF BACKGROUND DATA: LBP is a common secondary health condition after amputation with important implications related to function and quality of life. A growing body of evidence suggests that psychosocial factors influence LBP in patients without amputation. However, there is a dearth of information regarding the association of psychosocial factors and LBP after amputation. METHODS: Seventy-nine individuals with lower limb amputations who were a part of the Wounded Warrior Recovery Project were included in the analysis. Data on posttraumatic stress disorder (PTSD), depression, and quality of life (QOL) were collected from the Wounded Warrior Recovery Project, while data on LBP and LBP chronicity were extracted from the Military Health System Data Repository. General linear models were utilized to analyze associations between LBP and psychosocial factors, while controlling for injury severity and time since amputation. RESULTS: In individuals with amputations, 19.0% had acute LBP and 49.4% had recurrent LBP. Individuals with amputations and recurrent LBP reported higher PTSD symptom severity compared with those without LBP (B = 9.213, P < 0.05). More severe depression symptoms were observed in those with amputations and recurrent LBP compared with those without LBP (B = 5.626, P < 0.05). Among individuals with amputations, those with recurrent LBP reported lower QOL compared with those without LBP (B = -0.058, P < 0.05). There were no differences in PTSD, depression or QOL in those with amputations with and without acute LBP. CONCLUSIONS: Presence of recurrent LBP after amputation appears to be associated with more severe PTSD and depression symptoms as well as lower QOL. Further research is needed to assess the efficacy of addressing psychosocial factors for improving pain and function in service members with amputations and LBP. LEVEL OF EVIDENCE: 3.

Low back pain, mental health symptoms, and quality of life among injured service members.

OBJECTIVE: Pain is a significant public health issue that may be particularly problematic among injured service members who are at high risk of chronic physical and mental health conditions. The goals of this study were to describe the prevalence and types of low back pain (acute vs. recurrent) among service members injured while on combat deployments, and to examine the differences in posttraumatic stress disorder (PTSD) and depression prevalence and severity, as well as quality of life, for individuals with low back pain compared with those without. METHOD: Baseline assessment data from a subset of participants (n = 4,397) in the Wounded Warrior Recovery Project, a large, longitudinal examination of patient-reported outcomes, were used in conjunction with Department of Defense medical records data. RESULTS: Almost half of participants had acute or recurrent low back pain diagnoses, and the majority of individuals had no diagnosis of low back pain prior to their deployment-related injury. Individuals with low back pain, particularly recurrent, screened positive for PTSD and depression at higher rates, reported more severe symptoms of these disorders, and demonstrated poorer quality of life than those without. CONCLUSIONS: Low back pain was a prevalent issue among service members with deployment-related injury and was associated with worsened mental health outcomes and quality of life. Health care providers and researchers in multiple disciplines should consider the complex relationships between pain and mental health in order to further optimize treatment and outcomes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).