Chronic pain following major trauma: Prevalence,predictive models,and risk factors across common injury types

Abstract

Introduction

Chronic pain is a frequent and disabling complication following major trauma. Despite its high prevalence, it remains under-recognised and inconsistently managed. To review current evidence on the prevalence, risk factors and predictive models for chronic pain following major trauma, with comparison between musculoskeletal trauma, thoracic trauma, and spinal cord injury.

Methods

This narrative review follows PRISMA 2020 guidelines. Studies published between 2015 and March 2025 were included if they examined adults with major trauma and chronic pain. Thematic synthesis was performed and stratified by trauma sub-type.

Results

Chronic pain occurs in 30–70% of trauma survivors, with prevalence varying by injury type. Key risk factors include female sex, younger age, pre-existing pain, psychological distress, and social disadvantage. Validated prediction models are available for musculoskeletal trauma, while preventive strategies remain inconsistently applied across trauma sub-types.

Conclusion

Chronic pain after major trauma is common. A trauma-informed, proactive approach is needed to improve outcomes.

Keywords

Chronic pain major trauma musculoskeletal injury spinal cord injury thoracic trauma prevention prediction risk factors

Introduction

Major trauma is defined as physical injury with high risk of mortality, disability, or prolonged rehabilitation, typically reflected by an Injury Severity Score (ISS) > 15.^1,2 The global burden of major trauma is increasing, due to a rise in high-energy injuries among older adults and urban populations.¹ Improved pre-hospital and emergency care has also increased survival rates, leading to greater clinical focus on long-term complications.³

Chronic pain is defined by the International Association for the Study of Pain (IASP) as pain that persists or recurs for longer than 3 months and extends beyond the normal time of tissue healing.⁴ This condition can severely affect mobility, return to work (RTW), and psycho-social wellbeing.⁵ A clinically important sub-type is chronic post-surgical pain (CPSP), defined as pain that persists for at least 3 months after surgery and cannot be attributed to other causes. Early conceptual work by Bruce and Quinlan⁶ already emphasised the importance of recognising high-intensity acute post-operative pain as a predictor of future chronicity, which has since been confirmed by more recent models.⁷ Neuropathic pain, defined as pain caused by a lesion of the somatosensory nervous system and often described as burning, shooting, or electric in nature,⁸ is common in survivors of major trauma, especially those with peripheral nerve or spinal cord injury (SCI).⁹

Chronic post-traumatic pain (CPTP), defined as pain arising as a direct consequence of trauma and lasting beyond the expected period of recovery, remains under-recognised and inconsistently managed in clinical practice.^10,11 Reported prevalence ranges from 30% to 70%, depending on injury type, follow-up duration, and population studied.^1,12 One systematic review¹ reported a 63% prevalence of chronic pain following severe lower limb injury, while other studies demonstrated rates between 42%² and 57%¹³ in broader major trauma populations.

The persistence of CPTP is best understood through a biopsychosocial framework.¹⁴ Biological drivers include neuroinflammation, maladaptive neuroplasticity, and central sensitisation of pain pathways.⁸ Psychological factors such as depression, anxiety, and pain catastrophising have consistently been shown to worsen pain outcomes.^15–17 In addition, social determinants of health such as unemployment, limited health literacy, and restricted access to care increase vulnerability, particularly in patients with SCI or those experiencing chronic socioeconomic disadvantage.^12,18

Although prediction models and early interventions have been developed for patients with musculoskeletal trauma,^15,17,19 preventive care and tailored management strategies remain fragmented across trauma types. Evidence-based approaches are inconsistently implemented in perioperative and post-acute care settings.¹⁰

This narrative review aims to synthesise current evidence on the prevalence, risk factors, and prediction models for CPTP. A specific focus is placed on comparing musculoskeletal trauma, thoracic trauma, and SCI, with the goal of identifying shared and unique challenges to inform trauma-informed, perioperative pain management strategies.

Methods

This narrative was prepared following the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to enhance transparency and reproducibility in reporting.²⁰ A systematic literature search was performed in March 2025 across four databases: PubMed, Web of Science, Embase, and the Cochrane Library. The search was restricted to peer-reviewed articles published in English between January 2015 and March 2025 and focused on human populations. This time frame was selected to reflect contemporary developments in surgical and trauma care, given the substantial evolution in clinical techniques and protocols over the past decade.

Search terms included a combination of Medical Subject Headings (MeSH) and free-text keywords, such as ‘chronic pain’, ‘major trauma’, ‘chronic postsurgical pain’, ‘spinal cord injury’, and ‘traumatic rib fracture’. Boolean operators were applied to capture a comprehensive but targeted range of studies relevant to chronic pain following major trauma.

Duplicates were removed prior to screening. Titles and abstracts were initially screened, followed by full-text evaluation based on pre-defined inclusion and exclusion criteria. The search and selection process is illustrated in Figure 1, following the PRISMA 2020 guidelines.

Inclusion criteria:

Adults with sustained major trauma;

Post-trauma pain ≥3 months;

Addressed at least one of the following domains: prevalence, risk factors, or prediction models

Exclusion criteria:

Paediatric or non-human populations;

Were letters, case reports, or abstracts lacking full-text availability;

Not published in English.

The review focused on three trauma sub-types frequently associated with chronic pain: musculoskeletal trauma (including fractures and amputations), thoracic trauma (primarily rib fractures), and SCI. The findings were thematically synthesised and stratified by trauma sub-type. This comparative framework allowed for meaningful analysis across injury types, while accounting for heterogeneity in study design, populations, outcome measures, and follow-up durations.

Results

Prevalence

CPTP affects 30% to over 70% of trauma survivors, with wide variability depending on injury type and follow-up duration.^1,11,13 Neuropathic features were common, complicating management due to subjective experience, poor analgesic response, and co-morbid psychological symptoms.^1,21 In musculoskeletal trauma, especially lower limb injuries, CPTP often results from nerve damage or amputation.^2,21 Mahdi et al.¹ found a 38.3% prevalence at 12 months, with similar rates for amputation and limb salvage. This finding aligns with military data from upper-extremity trauma, where amputation and limb salvage yielded comparable long-term pain outcomes.²² Keene et al.²¹ reported 41% CPTP prevalence 6 months after surgery. Upper-extremity trauma with peripheral nerve injury is also associated with a high prevalence of chronic neuropathic pain, often leading to prolonged functional impairment.²³

Thoracic trauma, most commonly involving rib fractures, was associated with significant intercostal nerve damage.²⁴ Kim et al.²⁴ found that 36% of patients reported persistent pain 1 year after traumatic rib fracture, often affecting sleep and respiratory function. Long-term limitations in thoracic trauma patients were also described by Lucena-Amaro et al.,²⁵ who noted ongoing pain-related respiratory complaints beyond 12 months post-injury.

Among individuals with SCI, more than half reported CPTP within the first year post-injury.^5,11,18 Pain in this population typically involved both central and peripheral mechanisms and was associated with considerable psychological distress and functional disability.^26,27

Table 1 provides an overview of the included studies, categorised by trauma type and summarising key findings on chronic pain prevalence.

Table 1.

Overview of included studies, categorised according to trauma type.

Trauma type	Study	Number of patients	Population	Prevalence of chronic pain (%)	Follow-up	Key observations
Multi-trauma	Kolstadbraaten et al.¹³	68	Trauma with ISS ≥9	69	6 years	69% chronic pain; linked to sex, education, distress
Musculoskeletal	Keene et al.²¹	933	Surgery for lower limb trauma	41	3 and 6 months	Neuropathic pain; worse function and QoL
Musculoskeletal	Mahdi et al.¹	5601	SLLI	63	6–380 months	Similar chronic pain rates after amputation and limb salvage
Musculoskeletal + thoracic	Evans et al.²⁸	44	UK National Trauma Cohort	30–50	6 and 12 months	Mixed trauma; ISS predicts pain and disability
SCI	Andresen et al.⁵	537	Traumatic SCI in Denmark	54	3 −51 years	Neuropathic pain common and linked to poor QoL
SCI	Williams et al.¹⁸	13	International adults with traumatic SCI	53–63	3–6 years	Impacts mood, autonomy, and pain coping
Thoracic	Kim et al.²⁴	100	Multiple rib fractures	36	2 months to 3 years	Sleep disruption and physical limitations
Thoracic	Lucena-Amaro et al.²⁵	56	Rib fracture fixation	-	1–20 months	Long-term respiratory and pain complaints reported

ISS: Injury Severity Score; SCI: spinal cord injury, CPTP: chronic post-traumatic pain; SLLI: severe lower limb injury, QoL: quality of life.

Despite mechanistic differences, all injury types revealed a sustained and multi-dimensional burden of CPTP, with implications for long-term recovery, function, and quality of life.

Risk factors

CPTP has biological, psychological, and contextual causes.¹⁵ These differences are further compared across trauma types in Table 2, which summarises prevalence, risk factors, prediction models, and management strategies.

Table 2.

Comparison of chronic pain characteristics across trauma types.

Injury	Musculoskeletal trauma	Thoracic trauma	SCI
Prevalence	30–50% (up to 63% in SLLI)^1,13; common neuropathic component^21,29	∼36% CPTP after rib fractures, often neuropathic^24,25	>50% (often >60%); mainly neuropathic, central or mixed^5,9,10,18
Risk factors	Nerve damage, amputation, catastrophising, prior pain^2,11,12,30	Inadequate acute pain control, high ISS, flail chest^24,25	Central sensitisation, emotional burden, limited coping^10,18,27,31
Prediction models	Multiple validated tools (e.g. van Driel¹⁹, Rushton¹⁵)	No validated models; pain under-reported^24,25	No formal models; research ongoing¹⁰
Prevention	iPACT-E-Trauma, early self-management^16,17	Limited protocols; delayed recognition of risk^11,25	No structured prevention; opportunity in sub-acute phase^9,18
Management	Variable; self-management promising^17,32	NSAIDs, rib fixation (limited evidence), multi-modal approach recommended^24,25	Structured multi-disciplinary care; phenotype-driven^9,10,18

SLLI: severe lower limb injury; CPTP: chronic post-traumatic pain; SCI: spinal cord injury; iPACT-E-Trauma: intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma; NSAID: non-steroidal anti-inflammatory drug; ISS: Injury Severity Score.

In musculoskeletal trauma, key risk factors include peripheral nerve damage, high-energy fractures, amputation, and pre-existing pain.^1,21,22,30 Patients with prior pain history have up to three times higher CPTP risk. Younger age is also significant: Velmahos et al.¹² found a 58% prevalence in those under 40, and Powelson et al.² reported a 70% increased risk under age 45. Psychological factors like anxiety and catastrophising further increase CPTP risk, particularly when combined with limited coping skills and social disadvantage.

In thoracic trauma, insufficient acute pain management was commonly cited as a pre-cursor to persistent pain, including intercostal neuralgia and post-thoracotomy pain syndrome.²⁵ Additional risk factors included the presence of flail chest, high ISS, and pre-existing anxiety or psychological stress.^24,25,28 Other reported risk factors include female sex, a higher number of rib fractures (≥6), and severe pain intensity at admission, all of which have been associated with an increased risk of persistent thoracic pain.^24,25 These findings are consistent with observational data highlighting the psycho-social burden and prevalence of persistent pain following chest trauma.³³

Pain after SCI is mainly linked to central sensitisation and neuroinflammation, with surgery playing a minor role.¹¹ Psychological factors such as anxiety, depression, and catastrophising are common predictors across trauma types, particularly in SCI and musculoskeletal trauma where poor coping worsens outcomes.^10,18,30,32 Female sex and social disadvantage, including limited healthcare access and support, also increase risk, especially in thoracic and SCI cases with fragmented care.¹¹

Collectively, these findings highlight that CPTP arises from a multi-factorial interaction between individual vulnerability, injury severity, psycho-social context, and healthcare-related factors.

Prediction models

Prediction models help identify CPTP risk by combining clinical, psychological, and contextual factors.^15,34 Validated tools currently exist mainly for musculoskeletal trauma. van Driel et al.¹⁹ developed a four-variable model including pre-operative opioid use, bone surgery, post-operative day 14 pain score, and painful cold sensation, which showed good predictive value. Similarly, Rushton et al.¹⁵ introduced a screening tool based on pain interference, emotional state, and work ability.

Powelson et al.² applied a Cox regression model and identified younger age and high acute pain scores as significant predictors of CPTP. Papadomanolakis-Pakis et al.³⁴ systematically reviewed prognostic models for CPSP and identified key predictors such as pre-existing pain, catastrophising, and early post-operative pain. A more recent, internally validated model was proposed by the same group.³⁴ Sydora et al.³⁰ further synthesised pre-surgical risk factors relevant for future model development.

No validated models exist for thoracic trauma or SCI, despite known contributors like central sensitisation and psychological distress.^11,18 This gap limits early risk stratification and hinders targeted prevention.

Long-term management and functional recovery

Effective prevention of CPTP depends on the early identification of individuals at risk and the timely initiation of targeted interventions, as described by Papadomanolakis-Pakis et al.³⁴

While pharmacological strategies have shown limited sustained efficacy, behavioural, and educational approaches appear to offer more promise in reducing CPTP, particularly in musculoskeletal trauma.^15,17

The Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma) programme, developed for patients with acute lower limb trauma, integrates web-based education, goal setting, and coping strategies to target psychological risk factors like catastrophising and fear of movement. Early studies confirmed its feasibility and acceptability, though broader validation is still required.^15–17

Management of CPTP differs significantly between trauma types. In musculoskeletal trauma, early rehabilitation and self-management are central components of care, although long-term coordination is often lacking.¹⁷

In thoracic trauma, typically involving intercostal nerve damage, management tends to rely on short-term pharmacological treatment, with limited emphasis on chronic pain or structured follow-up care.^25,28 Rib fixation may be beneficial in selected cases, but current evidence remains inconclusive.

SCI care is generally more structured and multi-disciplinary, involving pharmacological agents such as pregabalin and amitriptyline, alongside physical therapy and psychological support.³¹ Nevertheless, patients with SCI frequently report fragmented services and poor communication across care providers.^10,18

Long-term opioid use remains a concern, particularly in musculoskeletal and thoracic trauma populations.^12,28,29 In patients with surgically treated lower limb trauma, neuropathic pain has been associated with increased use of pain medication and higher healthcare costs.²⁹ Persistent pain is strongly associated with continued opioid use, which may hinder functional recovery and increase the risk of long-term dependence.^12,28

RTW is substantially impaired by CPTP and its functional consequences. Among individuals with lower limb trauma, long-term incapacity is common.^1,32 In thoracic trauma, fewer than half of patients RTW following rib fracture fixation, likely due to ongoing pain and physical limitations.²⁵ For those with SCI, less than 30% are able to RTW, with chronic pain and spasticity frequently cited as major barriers.^5,31

To improve long-term outcomes across all trauma types and healthcare settings, a trauma-informed and individualised management approach is essential. This should integrate early screening, targeted preventive measures, and sustained biopsychosocial care throughout the recovery process.¹¹

Discussion

Chronic pain is a frequent and disabling consequence of major trauma, with prevalence estimates ranging from 30% to over 70%, depending on injury characteristics, underlying pathophysiology, and duration of follow-up.^1,2,13 This review highlights three findings.

Firstly, individuals with SCI experience the highest prevalence and most complex forms of CPTP, which are often neuropathic in nature and involve both central and peripheral mechanisms.^5,11,18

Secondly, musculoskeletal trauma is consistently associated with high rates of CPTP, especially with nerve injury or amputation.^1,21,33

Thirdly, thoracic trauma, although under-represented in the literature, contributes significantly to the chronic pain burden. This typically occurs through intercostal nerve damage and persistent pain following thoracic injury.^24,25,28

Across trauma types, chronic pain is shaped by biological factors like central sensitisation, psychological factors such as catastrophising and depression, and contextual elements including social support and care continuity.^15,17,18

These findings highlight the need for trauma-specific strategies that integrate biological, psychological, and contextual factors to improve the prediction, prevention, and management of CPTP.^10,12,19

Chronic pain differs by trauma type, requiring tailored clinical strategies. Musculoskeletal trauma, often involving peripheral nociceptive and neuropathic pain, is best studied for prevention and early intervention, particularly in orthopaedics.^1,15 Predictive tools and iPACT-E-Trauma exist but remain under-used.¹⁷

Thoracic trauma, though common, is under-represented in literature. Rib fractures and thoracotomy often cause intercostal nerve injury, resulting in persistent pain; respiratory problems, poor sleep, and reduced quality of life.^24,25,28 Despite this, standardised care pathways and predictive tools are lacking, and chronic thoracic pain remains under-recognised and poorly managed.²⁵

SCI presents the most complex pain profile. Patients often report both central and peripheral pain, along with spasticity and other neurogenic symptoms.^5,11,18 Despite multi-disciplinary care, assessment remains difficult due to central sensitisation and co-morbidities, and follow-up often lacks personalisation.^10,11

These differences highlight that CPTP is a heterogeneous set of overlapping syndromes, not a single entity. Each trauma type presents unique challenges, requiring tailored clinical approaches and informing research, education, and policy.^10,11

The sub-acute phase (10 days to 3 months) is critical but under-used. Pain trajectories established in this period are strong predictors of CPTP.^2,10 Severe acute pain, neuropathic symptoms, or psychological distress increase the risk of persistent pain. Early identification allows for timely, targeted intervention.¹⁵

Predictive tools developed by van Driel et al.¹⁹ and Rushton et al.¹⁵ in musculoskeletal trauma offer useful models for early risk stratification based on routinely collected clinical variables. However, no comparable tools currently exist for thoracic trauma or SCI, despite the distinct risk profiles associated with these populations.^11,18,24 Adapting these strategies to other trauma groups may improve early management and reduce the long-term burden of CPTP.

Continuity of care remains a major weakness. Many patients feel abandoned after discharge, often lacking clear follow-up or coordinated support.^18,32 Common barriers include poor access to multi-disciplinary care, limited psychological support, and unclear referral pathways.¹¹

These issues are especially pronounced in thoracic trauma and SCI populations, where persistent symptoms are common but frequently minimised or ignored in post-acute care settings.¹⁸ In SCI, fragmented care is further complicated by co-existing problems such as spasticity, neurogenic dysfunction, and central pain, which are rarely addressed through integrated models.¹⁰

Patients frequently report poor communication with healthcare providers and a lack of involvement in treatment decisions, which negatively affects their engagement with care and satisfaction with pain management outcomes.^11,18

Addressing these shortcomings requires systemic reform. Chronic pain screening, psychological evaluation, and rehabilitation planning should be integrated early in trauma care pathways.¹⁰ Stronger links between hospital and community care, alongside effective case management and patient-centred coordination, are essential to ensure continuity, especially for high-risk trauma populations.^10,18

Preventive strategies for CPTP show promise, yet clinical implementation remains inconsistent. Pharmacological interventions such as gabapentinoids and ketamine have demonstrated only limited and context-dependent benefits, with ongoing debate about their safety, efficacy, and appropriate indications.^10,35

Behavioural and educational strategies show promise, particularly in musculoskeletal trauma. The iPACT-E-Trauma programme targets modifiable psychological risk factors and has shown early feasibility, though broader validation is needed.^15,17

Despite frequent CPTP, preventive strategies in thoracic trauma remain scarce, particularly after rib fractures and thoracotomy.^2,28 Similarly, patients with SCI frequently report that chronic pain is treated as an unavoidable consequence of their injury, which reinforces therapeutic nihilism and results in missed opportunities for early intervention.^11,18

Greater focus on early and multi-modal prevention, especially during the sub-acute phase, may reduce chronic pain and improve long-term outcomes. This approach may reduce the long-term burden of chronic pain and improve quality of life across trauma populations.^10,11

Prediction models are essential tools for guiding prevention and early intervention strategies in CPTP.^10,15,19 However, current models are often limited by a lack of external validation, poor generalisability across trauma types, and insufficient integration of dynamic pain data over time.^15,19

Future models should include clinical features such as pain quality (e.g. burning or electric sensations), validated psychological tools like Hospital Anxiety and Depression Scale and Pain Catastrophising Scale, and contextual factors such as access to care and social support.^15,17,18 To be clinically useful, tools must be simple, effective, and integrated into follow-up pathways with room for regular reassessment.^10,11

The lack of validated prediction tools for thoracic trauma and SCI populations currently hampers the proactive identification of high-risk patients. Addressing this gap may improve early, personalised prevention efforts in these often-overlooked trauma groups.

This review is limited to English-language literature and does not include a registered protocol or formal quality appraisal. Its narrative design, single-reviewer synthesis, and lack of quantitative analysis may affect reproducibility. Variability in definitions and outcome measures also limits comparability across studies. Nonetheless, it is one of the few reviews to focus on CPTP across injury types, combining prevalence data with patient-reported outcomes to identify key clinical and research priorities.

Conclusion

Chronic pain after major trauma is common, multi-factorial, and often preventable.^1,2,13 A shift is needed from reactive symptom control to early, personalised pain care sustained throughout recovery.^10,11 Prediction, prevention, and patient-centred management should form the basis of trauma-informed strategies.^7,15,17,19 Simple screening tools and psycho-education offer practical first steps. A trauma-specific, biopsychosocial approach is key to reducing chronic pain and improving recovery.^11,18

Footnotes

Author contributions

Study concept and design: MK and DW.

Acquisition, analysis, and interpretation: MK and DW.

Drafting of the manuscript: MK.

Critical revision of the manuscript for important intellectual content: MK, DW, GH, and VS.

All the authors have read and approved the final manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Ethical approval was not sought for this article because it is a narrative review that synthesises and discusses data from previously published literature. No new patient data were collected or analysed.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed consent

Informed consent was not applicable for this article because it does not involve primary data collection or direct involvement of human subjects. All included studies had obtained appropriate consent as part of their original ethical approval.

ORCID iDs

Max Kussé

Guy Hans

Vera Saldien

Davina Wildemeersch

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