Rhon D, Teyhen D, Collins G, Bullock G

Abstract submitted to The World Congress of Sports Physical Therapy 2022

Using the same data, compare performance between an injury prediction model categorizing predictors and one that did not, and compare selection of predictors based on univariate significance versus assessing non-linear relationships. Validation and replication of a previously developed injury prediction model in a cohort of 1466 healthy military service members followed for one year after physical performance, medical history, and sociodemographic variables were collected. The original model dichotomized 8 predictors. The second model (M2) kept predictors continuous but assumed linearity, the third model (M3) conducted non-linear transformations. The fourth model (M4) chose predictors the proper way (clinical reasoning and supporting evidence) which led to an addition of 7 additional predictors (15 predictors total), but still kept predictors dichotomized. Model performance was assessed with R2, calibration in the large, calibration slope, and discrimination. Decision curve analyses were performed with risk thresholds from 0.25 to 0.50.

Rhon, D. I., Teyhen, D. S., Collins, G. S., & Bullock, G. S. (2022). Predictive Models for Musculoskeletal Injury Risk: Why statistical Approach Makes All the Difference. BMJ Open Sport & Exercise Medicine. https://doi.org/10.1136/bmjsem-2022-001388

Foster K, Greenlee T, Fraser J, Young J, Rhon D

Investigate the burden of knee, hip, and lumbar spine disorders occurring in the year following an ankle sprain and the influence therapeutic exercise (TE) has on this burden. 33,361 individuals diagnosed with ankle sprain in the Military Health System between 2010 and 2011 were followed for 1 year. Prevalence of knee, hip, and lumbar care-seeking injuries sustained after sprain was identified. Relationships between demographic groups, ankle sprain type, and use of TE with rate of proximal injuries were evaluated using Cox Proportional Hazard Models to determine Hazard Rate effect modification by attribute. Observed impact of TE for ankle sprain on rate of injury to proximal joints was evaluated using Kaplan-Meier survival analyses.

Foster, K. S., Greenlee, T. A., Fraser, J. J., Young, J. L., & Rhon, D. I. (2022). The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury. Medicine & Science in Sports & Exercise. https://doi.org/10.1249/MSS.0000000000003035

Foster K, Greenlee T, Young J, Janney C, Rhon D

Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70-2.79), increasing age (OR 1.03, 95% CI 1.02-1.04), female sex (OR 1.58, 95% CI 1.28-1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03-1.09), female sex (OR 2.73, 95% CI 1.74-4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03-2.89), and active-duty status (OR 2.28, 95% CI 1.38-3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28-0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries

Foster, K. S., Greenlee, T. A., Young, J. L., Janney, C. F., & Rhon, D. I. (2022). How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury? The Journal of Knee Surgery. https://doi.org/10.1055/s-0042-1751246

Powell J, Sparling T, Yuan X

Globally, 57.7 million people lived with traumatic limb loss in 2017, with the prevalence of amputation in the United States alone expected to reach 3.6 million by 2050. Pain is a common complication after limb loss, with up to 59% of patients experiencing residual limb pain (RLP). Although RLP is often due to a structural etiology, it is difficult to treat, as the exact structure involved is frequently not apparent on history and physical exam alone. This narrative review aims to summarize the available literature on diagnostic ultrasound (US) of the residual limb and examine the utility of US in identifying specific pathology. A total of 31 peer-reviewed manuscripts published between 1989 and 2021 were included, grouped by pathology. While US presents a promising and cost-effective approach to identifying pathology within the residual limb, many gaps remain in the current knowledge, and no specific protocol for a sonographic assessment of the residual limb has ever been proposed. Future studies of diagnostic US of the residual limb should focus on replicable sonographic techniques and standardized exam protocols.

Powell, J. E., Sparling, T. L., & Yuan, X. (2022). Diagnostic Ultrasound of the Residual Limb: A Narrative Review. PM&R. https://doi.org/10.1002/pmrj.12896

Super E, Smith M, Persinger J, Hager N, Smith J, Miller M, Yuan X

Abstract Submitted to WRNMMC Research and Innovation Month 2022

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. Interventional procedures for CTS include carpal tunnel (CT) injections and CT release (CTR). Variant anatomy increases the risk of iatrogenic injury and complications, impairing recovery and leading to post-procedural functional deficits. The objective of this study was to evaluate anatomic variations associated with CTS or at risk of injury during procedures using high-frequency ultrasound (HFUS). In this cross-sectional, observational study of 100 eligible patients (age: 44.4 ± 13.0 years, 37.0% female) referred for upper extremity (UE) electrodiagnostic studies (EDX), the MN was systematically evaluated using high-frequency ultrasound (HFUS) from the elbow to the CT outlet. The presence/absence of Martin-Gruber anastomosis (MGA), palmaris longus, and lumbrical intrusion with dynamic finger flexion at the CT inlet were documented, along with the course of the palmar cutaneous branch of the MN (PCBMN) and thenar motor branch (TMB. The cross-sectional area (CSA) of the MN at the level of the CT inlet and the transverse safe zone (TSZ) for CTR were measured. Statistical analyses were conducted using GraphPad Prism. All data are presented as mean ± standard deviation or percentage (%).

Pendlebury G, Rimmert B, Yuan X

Ischiofemoral impingement (IFI) is an uncommon etiology of hip pain, first reported in three patients after total hip arthroplasty and proximal femoral osteotomy. IFI is defined as a narrowing of the ischiofemoral space (IFS) between the lesser trochanter and ischium, leading to edema of the quadratus femoris (QF) muscle and sciatic nerve compression. Abnormalities of the QF may lead to hip, buttock, and groin pain radiating distally from the posterior thigh, likely due to irritation of the sciatic nerve adjacent to the QF.² Existing literature on this condition is limited, including case reports of congenital variants in women and children.³ We report the case of a 50-year-old woman with chronic right hip pain who was diagnosed with ischiofemoral impingement syndrome (IFIS) by physical examination findings and magnetic resonance imaging (MRI) results.

Pendlebury, G., Rimmert, B., & Yuan, X. (2022). Ischiofemoral Impingement Syndrome: Case Report and Treatment Review. Practical Pain Management

Smith M, Bradley M, Kasuske A, Smith J, Nanos G, Tintle S, Reece D, Yuan X, Miller M

Submitted to WRNMMC Research and Innovation Month 2022

Within the Military Healthcare System (MHS), endoscopic and mini-open carpal tunnel release (mOCTR) procedures are the current standard of care for management of refractory Carpal Tunnel Syndrome (CTS), the most common peripheral neuropathy. Carpal Tunnel Release using Ultrasound Guidance (CTR-US), which involves a single 4-6 mm incision, is showing potential as a treatment option for eligible candidates within the military population with CTS in an ongoing randomized controlled trial (RCT) at Walter Reed National Military Medical Center (WRNMMC).

Yuan X, Lowder R, Avilles- Wetherell K, Skroce C, Yao K, Soo Hoo J

Rehabilitation is the key to management of patients with subacromial impingement syndrome to prevent disability and loss of function. While point-of-care musculoskeletal ultrasound aids clinical diagnosis of subacromial impingement syndrome, many patients do not demonstrate the classic findings of dynamic supraspinatus tendon impingement beneath the acromion on ultrasound. The objective of this study was to establish the most reliable shoulder ultrasound measurements for subacromial impingement, by evaluating the intra-rater and inter-rater reliability of measurements in asymptomatic participants.

Yuan, X., Lowder, R., Aviles-Wetherell, K., Skroce, C., Yao, K. V., & Soo Hoo, J. (2022). Reliability of point-of-care shoulder ultrasound measurements for subacromial impingement in asymptomatic participants. Frontiers in Rehabilitation Science. https://doi.org/10.3389/fresc.2022.964613

Smith M, Huszar M, Pav V, Hando B, Deal J, Yuan X

Abstract submitted to SOMOS 64h Annual Meeting

Carpal Tunnel Syndrome (CTS) is the most common peripheral entrapment neuropathy, impacting the health, performance, and readiness of Active-Duty service members (ADSMs) of the U.S. Military. However, for ADSMs who seek surgical management for severe or refractory CTS with Carpal Tunnel Release (CTR), access to subspecialty providers within direct care (DC) Military Treatment Facilities (MTFs) can be limited, leading to reliance on care outside MTFs within the private sector (PS). It is currently unknown how the COVID-19 pandemic has impacted provision of and access to care for CTS and CTRs across DC and PS. Therefore, the purpose of this study is to describe regional trends and variation in CTRs performed across Defense Health Agency (DHA) markets within the Military Health System (MHS) over Fiscal Years (FY) 2019-2021. All study procedures were approved by the Uniformed Services University’s Institutional Review Board. We queried the MHS Data Repository to identify all ADSMs with outpatient encounters in DC and PS by International Classification of Diseases, Tenth Revision diagnosis codes for CTS, and CTRs by Current Procedural Terminology codes, during FYs 2019-2021. We further classified CTRs by FY, DC vs. PS, DHA markets, and setting [e.g., Ambulatory Surgical Center (ASC), clinic]. PS encounters were derived using per person per day logic and mapped to DHA markets by zip codes within 40 miles of MTF Service Areas.

Persinger J and Hager N

The Physical Medicine and Rehabilitation Clinic (PM&R) at Walter Reed National Military Medical Center (WRNMMC) augmented their high frequency ultra-sound systems with an ultra-high frequency ultrasound(UHFUS) system for use in the diagnosing and treatment of musculoskeletal (MSK) and nerve injury warfighters. The Visualsonics VevoMD is an UHFUS system with operating frequencies in the 24–70 MHz range as compared to the typical POC and tertiary care ultrasound systems operating in the15–22 MHz range. Access to this system afforded a unique opportunity to explore the usefulness of this cutting-edge technology in the unique settings of limb loss and multi-trauma in the military.

Persinger, J. E., & Hager, N. (2022). Unique Diagnostic Capabilities and Impact of Ultra-High Frequency Ultrasound in the Musculoskeletal Clinical Setting. Journal of Ultrasound in Medicine. https://doi.org/https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.16028

Cook C, Zhou L, Bolognesi M, Sheean A, Barlow B, Rhon D

Concomitant cruciate and meniscus injuries of the knee are generally associated with acute trauma and commonly treated with surgical intervention. Comorbidities (simultaneous presence of two or more medical conditions) may be acquired from changes in activity levels and lifestyle after an injury and/or treatment. This study aimed to compare differences in comorbidity proportions between surgical and nonsurgical approaches in Military Health System beneficiaries who had concurrent cruciate and meniscus injuries. The retrospective case control design included 36-month data that were analyzed to reflect 12 months prior to injury/surgery and 24 months after injury/surgery. A comparison of differences within and between groups in surgical and nonsurgical approaches was calculated and logistic regression was used to determine if surgery increased or decreased the odds of comorbidities at 24 months. In our sample of 2,438 individuals with concurrent meniscus and cruciate injury, 79.1% (n¼1,927) received surgical intervention and 20.9% (n¼511) elected for nonoperative management. All comorbidities demonstrated significant within-group differences from pre- to post surgery for those with a surgical intervention; approximately, half the comorbidities increased (i.e., concussion or traumatic brain injury, insomnia, other sleep disorders, anxiety, posttraumatic stress disorder, and tobacco abuse disorder), whereas the other half decreased (i.e., chronic pain, apnea, cardiovascular disease, metabolic syndrome, mental health other, depression, and substance abuse disorders). The odds of acquiring a comorbid diagnosis after surgery reflected the bivariate comparisons with half increasing and half decreasing in odds. To our knowledge, this is the first study to explore comorbidity changes with a control group for individuals with concurrent meniscus and cruciate injuries.

Cook, C. E., Liang, Z., Bolognesi, M., Sheean, A. J., Barlow, B. T., & Rhon, D. I. (2022). Does Surgery for Concomitant Cruciate and Meniscus Injuries Increase or Decrease Subsequent Comorbidities at 2 Years? The Journal of Knee Surgey. https://doi.org/10.1055/s-0042-1750046

Rhon D, Greenlee T, Carreño P, Patzkowski J, and Highland K

Most individuals undergoing elective surgery expect to discontinue opioid use after surgery, but many do not. Modifiable risk factors including psychosocial factors are associated with poor postsurgical outcomes. We wanted to know whether pain catastrophizing is specifically associated with postsurgical opioid and health-care use.

Rhon, D. I., Greenlee, T. A., Carreño, P. K., Patzkowski, J. C., & Highland, K. B. (2022). Pain Catastrophizing Predicts Opioid and Health-Care Utilization After Orthopaedic Surgery A Secondary Analysis of Trial Participants with Spine and Lower-Extremity Disorders. The Journal of Bone and Joint Surgery. https://doi.org/10.2106/JBJS.22.00177

Rhon D and Tucker C

Orthopaedic surgery has revolutionized the expectations for restoration of physical function after musculoskeletal injury and, along with physical therapy, has transformed the limits of recovery. Many orthopaedic procedures have a high success rate for improving quality of life and patient-reported outcomes, yet these procedures carry some level of risk, including postoperative complications. The stepped-care model of health care delivery, when applied to musculoskeletal care, recommends implementing less-intense and lower-risk treatments with known efficacy, such as promotion and education of self-management strategies and physical therapy, before more-invasive and higher-risk treatments such as surgery. This model of managing musculoskeletal disability can improve efficiency of care delivery and reduce medical costs at the health system level. Unfortunately, there is a documented lack of implementing an appropriate course of conservative care, especially physical therapy, prior to surgery across multiple orthopaedic disciplines including sports, spine, and trauma medicine and joint arthroplasty. Failure to respond to nonsurgical treatment has been suggested as a requisite component of the surgical appropriateness criteria, yet practical application can be elusive. Multiple barriers to adequate utilization of conservative treatment exist, including U.S. payment models that increase out-of-pocket expense for patients, negative patient perception of therapy, unreasonable patient expectations from therapy versus surgery, and communication barriers between patient, surgeon, and therapist. Surgeons should ensure that high-quality guidelineappropriate care is delivered early and adequately to their patients. Rehabilitation professionals have a responsibility to deliver high-value care, properly documenting the type and extent of treatment to improve surgical decision-making between surgeons and patients. Criteria to determine appropriateness for surgery should include a standardized and extensive assessment of failed therapies prior to certain elective surgeries. Improved collaboration between surgeons and rehabilitation professionals can result in improved outcomes for patients with musculoskeletal disorders.

Rhon, D. I., & Tucker, C. J. (2022). Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes. Arthroscopy, Sports Medicine, and Rehabilitation. https://doi.org/10.1016/j.asmr.2021.09.038

Tropf J, Colantonio D, Tucker C, Rhon D

Meniscus injuries occur at a higher rate in the military than the general population. Appropriate management and rehabilitation of meniscus injuries is important for maintaining readiness. The purpose of this study was to describe the health burden of meniscus injuries in the Military Health System (MHS) to identify the surgical intervention rate for meniscus injuries, and to determine which injury characteristics and demographic variables were associated with the likelihood of surgery after injury. The U.S. Department of Defense Management Analysis and Reporting Tool, a database of health care encounters by military personnel and dependents, was queried for encounters associated with a meniscal injury diagnosis between January 1, 2010, and December 31, 2011. Meniscus injuries were categorized into (1) isolated medial, (2) isolated lateral, (3) combined medial and lateral, and (4) unspecified cohorts. Patients under 18 and over 51 years were excluded, as well as patients without records at least 1 year prior to diagnosis or 2 years after. Relevant surgical procedures were identified with the Current Procedural Terminology (CPT) codes for arthroscopic surgery of the knee, meniscus repair, meniscectomy, and anterior cruciate ligament (ACL) reconstruction. There were 2,969 meniscus injuries meeting inclusion criteria during the study period. There were 1,547 (52.1%) isolated medial meniscus injuries, 530 (17.9%) isolated lateral meniscus injuries, 452 (15.3%) involved both menisci, and 435 (14.7%) were unspecified. The mean age was 35.5 years (standard deviation [SD] ¼ 9.3). An adjacent ligamentous injury occurred in 901 patients (30.3%). The treatment course led to arthroscopic surgery in 52.8% (n ¼ 1,568) of all meniscus injuries. Eighty-five percent (n ¼ 385) of combined medial and lateral tears, 54.9% of medial tears, and 51.6% of lateral tears underwent surgery. Partial meniscectomy was the most common procedure performed while 47.2% (n ¼ 1,401) of tears were not treated surgically. Bilateral meniscus injuries had 4.57 greater odds of undergoing knee arthroscopy (95% confidence interval [CI]: 3.46, 6.04), 2.42 times odds of undergoing a meniscus repair, and 4.59 times odds for undergoing a meniscus debridement (95% CI: 3.62, 5.82). The closed nature of the MHS allows reliable capture of surgical rates for meniscus injuries within the military population. Meniscus injuries are common in the military and impose a significant burden on the MHS. Appropriate management and rehabilitation of this injury is important for maintaining readiness.

Tropf, J. G., Colantonio, D. F., Tucker, C. J., & Rhon, D. I. (2022). Epidemiology of Meniscus Injuries in the Military Health System and Predictive Factors for Arthroscopic Surgery. The Journal of Knee Surgery. https://doi.org/10.1055/s-0042-1744189

Gaunaurd I, Gailey R, Symsack A, Isaacson B, Pasquina P

Abstract submitted to 44th ICMM World Congress on Military Medicine 2022

Service Members (SM) and Veterans with lower limb amputation (LLA) are at a high risk for developing secondary co-morbidities such as joint pain, osteoarthritis, chronic low back pain, and cardiovascular disease. To mitigate these secondary comorbidities, optimize long-term function, and increase quality of life, effective rehabilitation and innovative lifelong care is essential. Telerehabilitation has recently demonstrated to be a useful method of healthcare delivery, particularly benefitting individuals with physical limitations who are unable to attend outpatient physical therapy, such as patients following LLA. Wearable technology, such as mobile sensors, has the potential to augment current telerehabilitation practice and improve home walking and exercise compliance for those with LLA. Therefore, could this technology be used to provide “booster” prosthetic training to improve or reinforce current mobility and prosthetic use, promote an active, healthy lifestyles and mitigate adverse secondary comorbidities? To address this question, the Department of Defense (DoD) and Veterans supported the development of a program through the Joint Incentive Fund called the Mobile Device Outcomes-based Rehabilitation Program (MDORP). The MDORP is a comprehensive mobile rehabilitation program that is clinician-guided and incorporates the use of a mobile sensor system called the Rehabilitative Lower Limb Orthopedic Assistive Device (ReLOAD). The ReLOAD system provides: (1) assessment of walking quality at home and in the community for people with LLA, (2) real-time auditory feedback to correct the most prominent gait deviations, and (3) automatic prescription of home exercises that target balance and strength impairments related to their most prominent gait deviation. The primary objective of the study was to determine if the 8-week MDORP improved strength, mobility, and gait quality in SMs and Veterans with LLA.

Pasquina p, Jannace k, Nordstrom m, Gbade-Alabi o, Smolinski g

Selected for a podium presentation at the 44th ICMM World Congress on Military Medicine 2022 in Brussels

Gailey R, Gaunaurd I, Goss D, Bennett C, Isaacson B

Abstract submitted to 44th ICMM World Congress on Military Medicine 2022

Rhon D, Greenlee T, Fraser J

Abstract submitted to Military Health System Symposium 2021

In military service members, ankle injuries can substantially curtail the ability to complete duty requirements. Ankle injuries were the third leading factor of lost work time of the US Armed Forces in 2002, and by 2017-2018 they were ranked first for all U.S. Army soldiers. Timely interventions earlier in the injury course may have greater effectiveness than when care is delayed. No work has been done to look at the iterative effects of time to rehabilitation on risk for injury recurrence, or the impact of early treatment on downstream utilization of healthcare resources. It is possible that the timing of interventions influences outcomes after ankle sprain, similar to what has been found for musculoskeletal disorders in other body regions.

Isaacson B, Wagner L, West S, Lucio W, Yuan X, Hager N, Pasquina P

Abstract submitted to Military Health System Research Symposium 2022.

Musculoskeletal injuries (MSI) affect approximately 800,000 Service Members annually and result in 25 million limited duty days. These conditions are the primary reasons for medical discharge and downgrade, and result in 34% of evacuations from theatre. Most concerning is that the disability discharge rate for MSI has increased 13x between 1981 and 2005 (70 vs. 950 per 100,000 persons). The alarming increase of MSI has also been observed in the general population, with an estimated 126.6 million Americans (one in every two adults) affected by a musculoskeletal condition — comparable to the total percentage of Americans living with a chronic lung or heart condition and costing an estimated $213 billion. Given the strict requirements for physical fitness in the military and the impact of MSI on combat readiness, the Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization was established in 2019 to advance the treatment and preventive care for Service Members with non-combat related MSI. MIRROR coordinates inter-service partnerships with premier academic institutions, primary military treatment facilities (MTFs), and civilian sites that experience a high volume of MSI, but lack a robust infrastructure to conduct rigorous trials. MIRROR is based in the Department of Physical Medicine & Rehabilitation at the Uniformed Services University and closely aligns with the Defense Health Agency (DHA), Department of Defense (DoD) leadership, Joint Program Committee (JPC) chairs, and other high-level advisory groups. In addition, our Steering Committee, comprised of nationally-renowned military and civilian subject matter experts in various musculoskeletal subspecialties, provides guidance and oversight on MIRROR’s direction, scope, and overall methods. The MIRROR organization also incorporates select MSI sub-portfolios (i.e., orthopedics, interventional spine and pain management, physical and occupational therapy), under the direction of subject matter experts, to further advance our mission across all MSI research areas. Our representation across both operational leadership and research subspecialties allows MIRROR to maximize its impact throughout the MHS. To ensure that findings are clinically translational, data is collected using standardized protocol content, case report forms, and recruitment/outcomes captured through REDCap. Real-time feedback is provided using PowerBI to ensure that data can be presented in a highly efficient manger without the risk of protected health information (PHI) disclosure. This allows quick assessment of key performance indicators and provides useful data to understand healthcare disparities.

Greenlee T, Bullock G, Teyhen D, Rhon D

Abstract submitted to Military Health System Research Symposium 2022.

Prevalence and burden of musculoskeletal injuries for military service members are high, with recurrent injuries contributing to greater costs, more time lost from duty, and sub-optimal force readiness. Several psychological factors are associated with injury and return to work readiness in sport and occupational settings. We explored whether the psychological state of soldiers returning to duty following an injury could predict time-loss injury within the next year. We performed a secondary analysis of data from a longitudinal cohort study of soldiers returning to full duty after a recent thoracolumbar spine (TLS) or lower extremity (LE) injury after seeking medical care. A psychological profile (depression, anxiety, anger, fear, frustration, exercise enjoyment, job-, military-, and life-satisfaction, kinesiophobia, fear avoidance beliefs, pain catastrophizing, stress, and mood) was assessed via self-report at the point of initial return-to-duty and Soldiers were followed for one year.