PREDICT: Predicting Resilience Effects on Downstream Injuries and Costs over Time

Noncombat-related injuries, such as ankle sprains or low back pain, are very common MSKIs. Limited duty days (LDD) are analogous to “lost workdays,” where SMs are excused from full duty due to medical restrictions. These significantly impact soldier and Army-level readiness, and much research has attempted to identify risk factors for injury. Many injury-specific predictors have been identified, such as mechanism and severity of injury, clinical tests of range of motion, pain, and weight bearing ability. Factors such as sex, age, military unit type have also been identified. Functional performance measures including run times, movement screens, and proprioception are also predictive, but take time and manpower to assess. These findings have contributed greatly to our ability to predict injury, but the models leave a lot of variances unexplained. The best predictor of future injury is prior injury. While useful, this information is limited by the fact that >50% of the Army can be injured in a given year, and this dilutes the specificity of this prediction factor. Characteristics of prior injury history seem to contribute to subsequent injury risk but risk factors that predict initial injury have been reported to differ from those that predict a second injury. Chronicity is at the heart of the MSK health burden in the military. Recurrent injuries often lead to more invasive and costly treatment and are more likely to result in surgical intervention than new injuries. Knowing there is a high likelihood of soldier injury, it is critical that healthcare teams are prepared to help people recover well and quickly and to reduce the risk for repeated injury or continued disability. Although much research has focused on how to predict whether an injury will occur in the first place, less research has focused on predicting favorable outcomes after injury. Factors specifically influencing recurrent injury following an episodeof care require examination.

There is mounting evidence that psychosocial factors play significant roles in physical health. Better stress coping ability and greater hardiness are qualities of Special Forces Soldiers that likely contribute to their ability to exceptionally handle challenging and stressful situations. Even the most physically fit soldier may not perform well in the face of stress without strong psychological resilience. Contributions of resilience and coping to injury recovery and recurrence should be examined. Resilience is “the ability to successfully adapt to stressors, maintaining psychological well-being in the face of adversity.” Inverse correlations exist between resilience and knee and low back pain and between hardiness and future injury risk. Diversity in resilience has also been considered when tailoring patient-centered treatment approaches for chronic pain patients. High level athletes have found positive cognitive and behavioral coping strategies and absence of maladaptive coping strategies to be advantageous during recovery. Resilience and coping are not assessed formally in any way when evaluating patients with MSK injury. This project aims to understand the roles of resilience and coping in successful recovery and will advance knowledge in areas of injury prevention, reduction and rehabilitation by uncovering confounders to successful management, treatment and rehabilitation. We are interested in knowing if self-reported resilience and/or coping, measured at the first appointment for the injury, can predict if a person will recover, how long it will take, whether it will become a recurrent problem, and how many LDD the injury will translate to.

The goals of this study are to describe the nature of the relationship between resilience/coping and 1) proxies of soldier readiness and 2) burden of MSKI. We hypothesize that individuals with greater resilience and coping will have lower recurrence rates, fewer limited duty days, higher recovery rates and faster recovery, fewer injury-related medical visits, and lower inpatient and outpatient direct medical costs related to initial injury. We expect resilience and coping to be relatively stable over follow-up. The primary outcome is recurrence of injury within six months after index visit. We define recurrence as a 60-day gap in care and profile and then a subsequent repeated injury during follow-up. This data is currently collected by the military and the proposed study does not require patient consent or fitness testing, making this a simple yet effective way of improving injury prediction. Our approach assumes the multidimensional model of recovery for response to injury which acknowledges how personal factors, such as individual differences and injury-related factors (e.g., type, history), as well as situational factors directly impact cognitive appraisals of the situation. These antecedents impact rehabilitation and outcomes via indirect influence on emotional and behavioral responses during the process.