Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, post-concussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/ treatment interventions. Progress in overcoming these limitations has been challenging, because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large scale (n = 5,000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for one year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.

Debate continues regarding the influence of litigation on pain outcomes after motor vehicle collision (MVC). In this study we enrolled European Americans presenting to the emergency department (ED) in the hours after MVC (n = 948). Six weeks later, participants were interviewed regarding pain symptoms and asked about their participation in MVC-related litigation. The incidence and predictors of neck pain and widespread pain six weeks after MVC were compared among those engaged in litigation ("litigants") and those not engaged in litigation ("non-litigants"). Among the 859/948 (91%) participants completing six week follow-up, 711/849 (83%) were non-litigants. Compared to non-litigants, litigants were less educated and had more severe neck pain, overall pain, and a greater extent of pain at the time of ED evaluation. Among individuals not engaged in litigation, persistent pain six weeks after MVC was common: 199/711 (28%) had moderate or severe neck pain, 92/711 (13%) had widespread pain, and 29/711 (4%) had fibromyalgia-like symptoms. Incidence of all three outcomes was significantly higher among litigants. Initial pain severity in the ED predicted pain outcomes among both litigants and non-litigants. Markers of socioeconomic disadvantage predicted worse pain outcomes in litigants but not non-litigants, and individual pain and psychological symptoms were less predictive of pain outcomes among those engaged in litigation. These data demonstrate that persistent pain after MVC is common among those not engaged in litigation, and provide evidence for bidirectional influences between pain outcomes and litigation after MVC.

Individual vulnerability factors influencing the function of the hypothalamic-pituitary-adrenal (HPA) axis may contribute to the risk of the development of persistent musculoskeletal pain after traumatic stress exposure. The objective of the study was to evaluate the association between polymorphisms in the gene encoding FK506 binding protein 51, FKBP5, a glucocorticoid receptor co-chaperone, and musculoskeletal pain severity six weeks after two common trauma exposures. The study included data from two prospective emergency department-based cohorts: a discovery cohort (n=949) of European Americans experiencing motor vehicle collision and a replication cohort of adult European American women experiencing sexual assault (n=53). DNA was collected from trauma survivors at the time of initial assessment. Overall pain and neck pain six weeks after trauma exposure were assessed using a 0–10 numeric rating scale. After adjustment for multiple comparisons, six FKBP5 polymorphisms showed significant association (minimum p <0.0001) with both overall and neck pain in the discovery cohort. The association of rs3800373, rs9380526, rs9394314, rs2817032, and rs2817040 with neck pain and/or overall pain six weeks after trauma was replicated in the sexual assault cohort, showing the same direction of the effect in each case. The results of this study indicate that genetic variants in FKBP5 influence the severity of musculoskeletal pain symptoms experienced during the weeks after motor vehicle collision and sexual assault. These results suggest that glucocorticoid pathways influence the development of persistent post-traumatic pain, and that such pathways may be a target of pharmacologic interventions aimed at improving recovery after trauma.

Study Objectives Motor vehicle collisions (MVCs) are the second most common form of trauma among older adults. We sought to describe the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the emergency department (ED) after an MVC. Methods We conducted a prospective longitudinal study of patients aged 65 years or older who presented to one of eight EDs after MVC between June 2011 and June 2014 and were discharged home after evaluation. ED evaluation was done via in-person interview; follow-up data were obtained via mail-in survey or phone call. Pain severity (0-10 scale) overall and for 15 parts of the body (locations) were assessed at each follow-up time point. Principal component analysis was used to assess the dimensionality of the locations of pain data. Participants reporting pain severity ≥4 attributed to the MVC at six months were defined as having persistent pain. Results Of the 161 participants, 72% reported moderate to severe pain at the time of the ED evaluation. At six months, 26% of participants reported moderate to severe MVC-related pain. ED characteristics associated with persistent pain included acute pain severity, pain located in the head, neck, and jaw or low back and legs, poor self-rated health, less formal education, pre-MVC depressive symptoms, and patient's expected time to physical recovery more than 30 days. Compared to those without persistent pain, individuals with persistent pain were substantially more likely at 6 month follow-up to have also experienced a decline in their capacity for physical function (73% vs. 36%; difference = 37%, 95% CI 19%-52%), a new difficulty with activities of daily living (42% vs. 17%; difference = 26%, 95% CI 10%-43%), a one point or more reduction overall self-rated health on a 5-point scale (54% vs. 30%; difference = 24%, 95% CI 6%-41%), and a change in their living situation in order to obtain additional help (23% vs. 8%; difference = 15%, 95% CI 2%-31%). Conclusion Among older adults discharged home from the ED after evaluation following an MVC, persistent pain is common and frequently associated with functional decline and disability.