{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T19:56:15Z","timestamp":1776110175419,"version":"3.50.1"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"3-4","license":[{"start":{"date-parts":[[2023,9,1]],"date-time":"2023-09-01T00:00:00Z","timestamp":1693526400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"The ADVANCE charity, UK"},{"DOI":"10.13039\/100008473","name":"Bournemouth University","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100008473","id-type":"DOI","asserted-by":"publisher"}]},{"name":"The ADVANCE charity, UK"},{"DOI":"10.13039\/100008473","name":"Bournemouth University","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100008473","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,2,27]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n               <jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Combat-related traumatic injury (CRTI) adversely affects heart rate variability (HRV). The mediating effect of mental and physical health factors on the relationship between CRTI, its severity and HRV has not been previously studied and investigated.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Materials and Methods<\/jats:title>\n                  <jats:p>A cross-sectional mediation analysis of the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study was performed. The sample consisted of injured and uninjured British male servicemen who were frequency-matched based on their age, rank, role-in-theater, and deployment to Afghanistan (2003-2014). CRTI and injury severity (the New Injury Severity Scores [NISS] [NISS\u2009&amp;lt;\u200925 and NISS\u2009\u2265\u200925]) were included as exposure variables. HRV was quantified using the root mean square of successive differences (RMSSD) obtained using pulse waveform analysis. Depression and anxiety mediators were quantified using the Patient Health Questionnaire and Generalized Anxiety Disorder, respectively. Body mass index and the 6-minute walk test (6MWT) represented physical health measures. Two mediation pathways between exposure and outcome variables were examined in comparison with the uninjured group using structural equation modeling.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Of 862 servicemen, 428 were injured and 434 were uninjured with the mean age at assessment of 33.9\u2009\u00b1\u20095.4 (range 23-59) years. Structural equation modeling revealed that depression, anxiety, and body mass index did not significantly mediate the relationship between injury\/injury severity and RMSSD. However, the 6MWT significantly mediated the relationship between CRTI and RMSSD (27% mediation). The indirect effect of 6MWT on the relationship between injury severity (NISS\u2009\u2265\u200925 vs. uninjured) and RMSSD was \u22120.06 (95% CI: \u22120.12, \u22120.00, P\u2009&amp;lt;\u2009.05).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>The findings suggest that greater physical function may improve HRV following CRTI. Longitudinal studies are warranted to further validate these findings.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/milmed\/usad341","type":"journal-article","created":{"date-parts":[[2023,9,1]],"date-time":"2023-09-01T15:46:37Z","timestamp":1693583197000},"page":"e758-e765","source":"Crossref","is-referenced-by-count":3,"title":["The Influence of\u00a0Physical and\u00a0Mental Health Mediators on\u00a0the Relationship Between Combat-Related Traumatic Injury and\u00a0Ultra-Short-Term Heart Rate Variability in\u00a0a U.K. Military Cohort: A Structural Equation\u00a0Modeling Approach"],"prefix":"10.1093","volume":"189","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8551-0442","authenticated-orcid":false,"given":"Rabeea","family":"Maqsood","sequence":"first","affiliation":[{"name":"Faculty of Health & Social Sciences, Bournemouth University , Bournemouth BH8 8GP, UK"},{"name":"National Heart and Lung Institute, Faculty of Medicine, Imperial College London , London SW3 6LR, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susie","family":"Schofield","sequence":"additional","affiliation":[{"name":"National Heart and Lung Institute, Faculty of Medicine, Imperial College London , London SW3 6LR, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander N","family":"Bennett","sequence":"additional","affiliation":[{"name":"National Heart and Lung Institute, Faculty of Medicine, Imperial College London , London SW3 6LR, UK"},{"name":"Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate , Nottinghamshire LE12 5QW, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed","family":"Khattab","sequence":"additional","affiliation":[{"name":"Faculty of Health & Social Sciences, Bournemouth University , Bournemouth BH8 8GP, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carol","family":"Clark","sequence":"additional","affiliation":[{"name":"Faculty of Health & Social Sciences, Bournemouth University , Bournemouth BH8 8GP, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anthony M J","family":"Bull","sequence":"additional","affiliation":[{"name":"Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London , London SW7 2AZ, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicola T","family":"Fear","sequence":"additional","affiliation":[{"name":"Academic Department of Military Mental Health and King\u2019s Centre for Military Health Research, King\u2019s College London , London SE5 9RJ, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher J","family":"Boos","sequence":"additional","affiliation":[{"name":"Faculty of Health & Social Sciences, Bournemouth University , Bournemouth BH8 8GP, UK"},{"name":"Department of Cardiology, University Hospitals Dorset , Poole BH15 2JB, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2023,9,1]]},"reference":[{"issue":"2","key":"2024022722265949400_R1","doi-asserted-by":"publisher","first-page":"151","DOI":"10.1111\/j.1542-474X.1996.tb00275.x","article-title":"Heart rate variability: standards of\u00a0measurement, physiological interpretation, and\u00a0clinical use: Task Force of\u00a0the European Society of\u00a0Cardiology and\u00a0the North American Society for\u00a0Pacing and\u00a0Electrophysiology","volume":"1","author":"Malik","year":"1996","journal-title":"Ann Noninvasive Electrocardiol"},{"issue":"2","key":"2024022722265949400_R2","doi-asserted-by":"publisher","first-page":"148","DOI":"10.1177\/1751143719853744","article-title":"Heart rate variability: measurement and\u00a0emerging use in\u00a0critical care medicine","volume":"21","author":"Johnston","year":"2020","journal-title":"J Intensive Care Soc"},{"issue":"3","key":"2024022722265949400_R3","doi-asserted-by":"publisher","first-page":"94","DOI":"10.1049\/htl.2017.0090","article-title":"Are ultra-short heart rate variability features good surrogates of\u00a0short-term ones? State-of-the-art review and\u00a0recommendations","volume":"5","author":"Pecchia","year":"2018","journal-title":"Healthc Technol Lett"},{"issue":"9","key":"2024022722265949400_R4","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0138921","article-title":"Validity of\u00a0(ultra-) short recordings for\u00a0heart rate variability measurements","volume":"10","author":"Munoz","year":"2015","journal-title":"PLoS One"},{"issue":"5","key":"2024022722265949400_R5","doi-asserted-by":"publisher","first-page":"S13","DOI":"10.1097\/01.TA.0000057151.02906.27","article-title":"A profile of\u00a0combat injury","volume":"54","author":"Champion","year":"2003","journal-title":"J Trauma Acute Care Surg"},{"issue":"5","key":"2024022722265949400_R6","doi-asserted-by":"publisher","first-page":"355","DOI":"10.1136\/jramc-2015-000490","article-title":"Died of\u00a0wounds: a mortality review","volume":"162","author":"Keene","year":"2016","journal-title":"BMJ Mil Health"},{"issue":"3","key":"2024022722265949400_R7","doi-asserted-by":"publisher","first-page":"713","DOI":"10.1007\/s11606-020-06195-1","article-title":"The enduring health consequences of\u00a0combat trauma: a legacy of\u00a0chronic disease","volume":"36","author":"Stewart","year":"2021","journal-title":"J Gen Intern Med"},{"issue":"1","key":"2024022722265949400_R8","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0280718","article-title":"Association between non-acute traumatic injury (TI) and\u00a0heart rate variability (HRV) in\u00a0adults: a systematic review and\u00a0meta-analysis","volume":"18","author":"Maqsood","year":"2023","journal-title":"PLoS One"},{"key":"2024022722265949400_R9","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2011\/416590","article-title":"Clinical applications of\u00a0heart rate variability in\u00a0the triage and\u00a0assessment of\u00a0traumatically injured patients","volume":"2011","author":"Ryan","year":"2011","journal-title":"Anesthesiol Res Pract"},{"key":"2024022722265949400_R10","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1136\/military-2022-002316","article-title":"Relationship between combat-related traumatic injury and\u00a0ultrashort term heart rate variability in\u00a0a UK military cohort: findings from the ADVANCE study","author":"Maqsood","year":"2023","journal-title":"BMJ Mil Health"},{"issue":"12","key":"2024022722265949400_R11","doi-asserted-by":"publisher","first-page":"1948","DOI":"10.1017\/S0033291719001351","article-title":"A meta-analysis of\u00a0heart rate variability in\u00a0major depression","volume":"49","author":"Koch","year":"2019","journal-title":"Psychol Med"},{"key":"2024022722265949400_R12","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyt.2014.00080","article-title":"Anxiety disorders are associated with reduced heart rate variability: a meta-analysis","volume":"5","author":"Chalmers","year":"2014","journal-title":"Front Psychiatry"},{"issue":"3","key":"2024022722265949400_R13","doi-asserted-by":"publisher","first-page":"300","DOI":"10.1007\/s12603-014-0022-6","article-title":"Body mass index is related to autonomic nervous system activity as measured by heart rate variability\u2014a replication using short term measurements","volume":"18","author":"Koenig","year":"2014","journal-title":"J Nutr Health Aging"},{"issue":"8","key":"2024022722265949400_R14","doi-asserted-by":"publisher","DOI":"10.3390\/ijms22084215","article-title":"Obesity, nutrition, and\u00a0heart rate variability","volume":"22","author":"Str\u00fcven","year":"2021","journal-title":"Int J Mol Sci"},{"key":"2024022722265949400_R15","doi-asserted-by":"publisher","first-page":"409","DOI":"10.2147\/VHRM.S212729","article-title":"Retrospective study of\u00a0cardiovascular disease risk factors among a cohort of\u00a0combat veterans with lower limb amputation","volume":"15","author":"Bhatnagar","year":"2019","journal-title":"Vasc Health Risk Manag"},{"issue":"2","key":"2024022722265949400_R16","doi-asserted-by":"publisher","first-page":"325","DOI":"10.1097\/TA.0000000000002999","article-title":"Time to weigh in\u00a0on obesity and\u00a0associated comorbidities in\u00a0combat-wounded amputees","volume":"90","author":"Tavares","year":"2021","journal-title":"J Trauma Acute Care Surg"},{"issue":"5","key":"2024022722265949400_R17","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1136\/heartjnl-2021-320296","article-title":"Association between combat-related traumatic injury and\u00a0cardiovascular risk","volume":"108","author":"Boos","year":"2022","journal-title":"Heart"},{"issue":"7","key":"2024022722265949400_R18","doi-asserted-by":"publisher","first-page":"931","DOI":"10.1682\/JRRD.2012.05.0098","article-title":"Comparison of\u00a06-minute walk test performance between male Active Duty soldiers and\u00a0servicemens with and\u00a0without traumatic lower-limb loss","volume":"50","author":"Linberg","year":"2013","journal-title":"J Rehab Res Dev"},{"issue":"2","key":"2024022722265949400_R19","doi-asserted-by":"publisher","first-page":"159","DOI":"10.1682\/JRRD.2014.07.0166","article-title":"Lower-limb amputation and\u00a0body weight changes in\u00a0men","volume":"52","author":"Littman","year":"2015","journal-title":"J Rehab Res Dev"},{"issue":"7","key":"2024022722265949400_R20","doi-asserted-by":"publisher","first-page":"547","DOI":"10.1016\/S2215-0366(22)00112-2","article-title":"Mental health outcomes of\u00a0male UK military personnel deployed to Afghanistan and\u00a0the role of\u00a0combat injury: analysis of\u00a0baseline data from the ADVANCE cohort study","volume":"9","author":"Dyball","year":"2022","journal-title":"Lancet Psychiat"},{"key":"2024022722265949400_R21","doi-asserted-by":"publisher","first-page":"S45","DOI":"10.1016\/j.jsams.2017.08.003","article-title":"Associations of\u00a0age, aerobic fitness, and\u00a0body mass index with injury in\u00a0an operational Army brigade","volume":"20","author":"Rappole","year":"2017","journal-title":"J Sci Med Spot"},{"issue":"10","key":"2024022722265949400_R22","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2020-037850","article-title":"Study protocol for\u00a0a prospective, longitudinal cohort study investigating the medical and\u00a0psychosocial outcomes of\u00a0UK combat casualties from the Afghanistan war: the ADVANCE study","volume":"10","author":"Bennett","year":"2020","journal-title":"BMJ Open"},{"issue":"05","key":"2024022722265949400_R23","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1016\/j.cjtee.2021.01.006","article-title":"New injury severity score (NISS) outperforms injury severity score (ISS) in\u00a0the evaluation of\u00a0severe blunt trauma patients","volume":"24","author":"Li","year":"2021","journal-title":"Chinese J Traumatol"},{"issue":"2","key":"2024022722265949400_R24","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1111\/j.1542-474X.2011.00417.x","article-title":"Reliability of\u00a0ultra-short ECG indices for\u00a0heart rate variability","volume":"16","author":"Nussinovitch","year":"2011","journal-title":"Ann Noninvasive Electrocardiol"},{"issue":"12","key":"2024022722265949400_R25","doi-asserted-by":"publisher","first-page":"2354","DOI":"10.1016\/j.apmr.2008.05.021","article-title":"Six-minute walk test in\u00a0persons with transtibial amputation","volume":"89","author":"Lin","year":"2008","journal-title":"Arch Phys Med Rehab"},{"issue":"9","key":"2024022722265949400_R26","doi-asserted-by":"publisher","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9: validity of\u00a0a brief depression severity measure","volume":"16","author":"Kroenke","year":"2001","journal-title":"J Gen Intern Med"},{"issue":"10","key":"2024022722265949400_R27","doi-asserted-by":"publisher","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","article-title":"A brief measure for\u00a0assessing generalized anxiety disorder: the GAD-7","volume":"166","author":"Spitzer","year":"2006","journal-title":"Arch Intern Med"},{"issue":"6","key":"2024022722265949400_R28","doi-asserted-by":"publisher","first-page":"1259","DOI":"10.3945\/ajcn.117.152546","article-title":"Best (but oft-forgotten) practices: mediation analysis","volume":"105","author":"Fairchild","year":"2017","journal-title":"Am J Clin Nutr"},{"issue":"2 Suppl","key":"2024022722265949400_R29","doi-asserted-by":"publisher","first-page":"S101","DOI":"10.1037\/0278-6133.27.2(Suppl.).S101","article-title":"How and\u00a0why criteria defining moderators and\u00a0mediators differ between the Baron & Kenny and\u00a0MacArthur approaches","volume":"27","author":"Chmura Kraemer","year":"2008","journal-title":"Health Psychol"},{"issue":"5","key":"2024022722265949400_R30","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1159\/000517518","article-title":"When anxiety and\u00a0depression coexist: the role of\u00a0differential diagnosis using clinimetric criteria","volume":"90","author":"Cosci","year":"2021","journal-title":"Psychother Psychosom"},{"issue":"2","key":"2024022722265949400_R31","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1002\/pri.398","article-title":"The six-minute walk test in\u00a0outpatients with obesity: reproducibility and\u00a0known group validity","volume":"13","author":"Larsson","year":"2008","journal-title":"Physiother Res Int"},{"issue":"3","key":"2024022722265949400_R32","doi-asserted-by":"publisher","first-page":"220","DOI":"10.1001\/archgenpsychiatry.2010.2","article-title":"Overweight, obesity, and\u00a0depression: a systematic review and\u00a0meta-analysis of\u00a0longitudinal studies","volume":"67","author":"Luppino","year":"2010","journal-title":"Arch Gen Psychiatry"},{"issue":"2","key":"2024022722265949400_R33","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1007\/s40211-019-0302-9","article-title":"Obesity and\u00a0anxiety symptoms: a systematic review and\u00a0meta-analysis","volume":"33","author":"Amiri","year":"2019","journal-title":"Neuropsychiatrie: Klinik, Diagnostik, Therapie Und Rehabilitation: Organ der Gesellschaft Osterreichischer Nervenarzte und Psychiater"},{"issue":"1","key":"2024022722265949400_R34","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/10705519909540118","article-title":"Cutoff criteria for\u00a0fit indexes in\u00a0covariance structure analysis: conventional criteria versus new alternatives","volume":"6","author":"Hu","year":"1999","journal-title":"Struct Equ\u00a0Modell"},{"issue":"1","key":"2024022722265949400_R35","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1207\/s15327906mbr3901_4","article-title":"Confidence limits for\u00a0the indirect effect: distribution of\u00a0the product and\u00a0resampling methods","volume":"39","author":"MacKinnon","year":"2004","journal-title":"Multivar Behav Res"},{"issue":"1","key":"2024022722265949400_R36","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1016\/j.ejcnurse.2008.07.001","article-title":"A review of\u00a0the six-minute walk test: its implication as a self-administered assessment tool","volume":"8","author":"Du","year":"2009","journal-title":"Eur J Cardiovasc Nurs"},{"issue":"16","key":"2024022722265949400_R37","doi-asserted-by":"publisher","DOI":"10.3390\/ijms21165895","article-title":"Possible neuroprotective mechanisms of\u00a0physical exercise in\u00a0neurodegeneration","volume":"21","author":"Mahalakshmi","year":"2020","journal-title":"Int J Mol Sci"},{"issue":"3","key":"2024022722265949400_R38","doi-asserted-by":"publisher","first-page":"288","DOI":"10.1016\/j.ijpsycho.2013.06.018","article-title":"The relationship between mental and\u00a0physical health: insights from the study of\u00a0heart rate variability","volume":"89","author":"Kemp","year":"2013","journal-title":"Int J Psychophysiol"},{"issue":"2","key":"2024022722265949400_R39","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1097\/00008483-200103000-00005","article-title":"Reference values for\u00a0a multiple repetition 6-minute walk test in\u00a0healthy adults older than 20 years","volume":"21","author":"Gibbons","year":"2001","journal-title":"J Cardiopulm Rehabil"},{"key":"2024022722265949400_R40","doi-asserted-by":"publisher","first-page":"78","DOI":"10.1016\/j.jclinepi.2019.10.001","article-title":"The conduct and\u00a0reporting of\u00a0mediation analysis in\u00a0recently published randomized controlled trials: results from a methodological systematic review","volume":"117","author":"Vo","year":"2020","journal-title":"J Clin Epidemiol"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/189\/3-4\/e758\/56773479\/usad341.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/189\/3-4\/e758\/56773479\/usad341.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,2,27]],"date-time":"2024-02-27T23:27:22Z","timestamp":1709076442000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/189\/3-4\/e758\/7258502"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,1]]},"references-count":40,"journal-issue":{"issue":"3-4","published-online":{"date-parts":[[2023,9,1]]},"published-print":{"date-parts":[[2024,2,27]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usad341","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2024,3,1]]},"published":{"date-parts":[[2023,9,1]]}}}