Early codevelopment of pain, sleep disturbance, and hyperarousal after traumatic injury

Chronic pain after traumatic injury likely reflects interacting processes rather than isolated recovery pathways, yet longitudinal evidence examining the joint development of pain, sleep disturbance, and hyperarousal from the acute postinjury stage is limited. We analysed data from the AURORA cohort of emergency department trauma survivors recruited within 72 hours of injury (n = 2834) to characterise trajectories of pain, sleep discontinuity, and hyperarousal over 12 months, identify shared multitrajectory profiles, and examine factors associated with adverse outcomes. Smartphone-based surveys assessed symptoms repeatedly from 1 to 5 days postinjury to one year. Group-based trajectory modelling identified 5 pain (n = 1635), 6 sleep discontinuity (n = 1635), and 5 hyperarousal (n = 1820) trajectories, ranging from rapid recovery to persistent high symptoms. Persistent high pain occurred in 35.1% of participants, while 23.5% followed persistently high or worsening sleep trajectories and 27.2% followed high hyperarousal trajectories. Multitrajectory modelling (n = 1800) identified 6 joint profiles, with 10.6% experiencing persistently high symptoms across all domains and 25.7% showing medium symptom levels. Older age and higher pretrauma pain were associated with adverse trajectories, whereas resilience and better prior mental health were protective. Baseline sleep discontinuity showed the strongest association with persistent high pain (adjusted odds ratio 3.31; 95% confidence interval 2.61-4.18), while physical activity was associated with a lower likelihood of medium-to-high pain trajectories. Female sex and lower income were associated with the most adverse multidomain profile. These findings highlight early postinjury sleep disruption, hyperarousal, and pain as interconnected processes. Targeting multiple domains may offer a promising strategy to prevent chronic pain after injury.