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. Author manuscript; available in PMC: 2026 Oct 7.
Published before final editing as: Rehabil Psychol. 2026 Oct 5:10.1037/rep0000696. doi: 10.1037/rep0000696

Cognitive Appraisal Processes Mediate Post-Injury Pain and Disability: A Longitudinal Observational Study

Enzo G Plaitano 1,2, Hanan H Hamed 2,3, Eric Kuhn 4,5, Brian P Suffoletto 6, Maria L Pacella-LaBarbara 2
PMCID: PMC13641149  NIHMSID: NIHMS2208455  PMID: 42831843

Abstract

Purpose/Objective:

Psychological appraisal processes of pain catastrophizing (PC) and perceived injustice (PI) are involved in the transition to post-injury disability. Although these factors are modifiable and may serve as ideal intervention targets to improve recovery, they have not been examined as mediators between acute pain and post-injury disability. The present study utilized longitudinal mediation to examine acute PC and PI as mechanisms by which acute pain contributes to 90-day disability in adults after a motor vehicle crash (MVC).

Research method/Design:

This study represents secondary data analysis of a null randomized controlled trial. In total, 47 Emergency Department (ED) patients (M age = 37 years; 64% female) completed an assessment within 24 hours post-injury, and 30-day and 90-day follow-up assessments on post-injury PC, PI and disability. We utilized longitudinal mediation models to estimate direct and indirect effects adjusted for age, sex, pre-injury disability, and intervention.

Results:

Higher levels of PI and PC were associated with greater disability. There was a statistically significant indirect effect for PC and PI, suggesting that the relationship between ED pain and 90-day disability was partially explained by these psychological appraisal mechanisms.

Conclusions/Implications:

Patients at-risk for post-injury disability display higher levels of PC, in the form of rumination, feeling helpless, or magnifying their pain, and higher levels of perceived injustice, via blaming others for their situation. Future work is warranted to determine if interventions targeting these mechanisms may help improve long-term post-injury recovery.

Keywords: pain catastrophizing, perceived injustice, pain, disability, motor vehicle crash

In the United States, motor vehicle crash (MVC)-related injury accounts for approximately 3.8 million emergency department (ED) visits each year, representing one of the leading causes of injury among all age groups (Davis & Cairns, 2023). Notably, approximately 43% of adults with mild to moderate injuries will develop chronic pain (e.g., pain for > 90 days post-injury) within two years of experiencing an MVC (Pilet et al., 2023). This transition to chronic pain (Treede et al., 2019) can impair quality of life through higher functional disability, reliance on healthcare services, and reduced participation in social activities (Pilet et al., 2023).

Understanding potentially modifiable factors that contribute to disability prior to pain chronification can help reduce long-term disability (Treede et al., 2019). Informed by the biopsychosocial model of pain, appraisal processes of pain catastrophizing (PC) and perceived injustice (PI) may shape post-injury disability beyond physical injuries (Gatchel et al., 2020). PC is defined as ruminating about pain, pervasive negative thinking about pain, magnification of pain, and helplessness (Miller et al., 2022; Simic et al., 2024); while PI is defined as irreparable loss, amplifying severity, blame, and feelings of unfairness (Miller et al., 2022; Trost et al. 2024).

Although PC is associated with greater disability within 90-days post-injury (Gnall et al., 2025; Pedrero-Martin et al., 2024), and mediates relationships between pain intensity and disability in patients with chronic pain (Besen et al., 2017; Ullrich et al., 2007), relationships have yet to be examined immediately post-injury. Extant research also suggests that PI is associated with disability and pain intensity after sustaining a traumatic injury (Trost et al. 2024) and later post-injury (Sullivan et al., 2009; van Leeuwen et al., 2016; Yakobov et al., 2018). However, PI has only been observed as a mediator between pain intensity and 90-day quality of life in adolescents with chronic pain (Lee et al., 2015; Miller et al., 2022; Sullivan et al., 2012).

To address these gaps, the present study utilized longitudinal mediation analyses to examine 30-day PC and PI as psychological mediators between ED pain and 90-day disability in adults treated after an MVC. These results can inform the development of interventions to reduce post-injury disability. We hypothesize that PC and PI will each mediate the relationships (e.g., significant indirect, non-significant direct effects) between acute pain and 90-day disability.

Methods

Transparency and Openness.

We conducted a secondary data analysis of a completed null randomized controlled trial on the impact of a smartphone app designed to help manage PTSD-related symptoms (ClinicalTrials.gov Identifier: NCT03247179). The University of Pittsburgh Human Research Protection Office (#PRO16010595) approved this research project. We did not file an initial data sharing plan, and since the study is now closed, for ethical reasons, we are unable to share the data on which the study conclusions are based.

Participants.

Individuals aged 18–65 years old were recruited in the EDs of two urban Level 1 trauma centers within 24 hours of an MVC-related injury (N = 47) from September 2017 until September 2018 for enrollment in a null clinical trial. Inclusion and exclusion criteria were previously published in further detail (Pacella et al., 2020). Inclusion criteria were limited to individuals who had at least one MVC-related musculoskeletal injury, self-reported exposure to life-threatening situations or perceived serious injury (i.e., Criterion A for PTSD), and self-reported a pain intensity score ≥ 4 (from 0–10; higher numbers indicated greater pain).

Procedure.

A comprehensive overview of the recruitment process and a CONSORT diagram have been previously outlined (Pacella et al., 2020). After obtaining written informed consent, participants were randomly assigned to a digital health intervention or the treatment as usual. Participants completed self-report surveys in the ED post-injury on an iPad through Research Electronic Data Capture (REDCap) (Harris et al., 2009). Follow-up surveys were completed remotely via a secure survey link at 30 (e.g., PI and PC) and 90 days (e.g., disability) post-injury. Participants were compensated up to $80 total for survey completion.

Pain Catastrophizing.

PC was assessed at 30 days post-injury using the 13-item Pain Catastrophizing Scale (PCS). This scale measured thoughts and feelings regarding pain stemming directly from their MVC-related injury (Sullivan et al., 1995). Items are rated from 0 (not at all) to 4 (all the time) and were summed to create a total score (0–52); higher scores indicated higher levels of PC (Sullivan et al., 1995). Internal consistency was excellent (α = .98).

Perceived Injustice.

PI was assessed at 30 days post-injury using a 12-item modified version of the Injustice Experiences Questionnaire (IEQ) (Sullivan et al., 2008) anchored to the injury and rated from 0 (not at all) to 5 (all the time). Items were summed to a total (0–60); higher scores indicated higher PI (Sullivan et al., 2008). Internal consistency was excellent (α = .96).

Disability.

Our primary outcome was degree of disability in daily activities in the past 30-days, assessed in the ED (pre-injury) and 90-days post injury using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) (Üstün et al., 2010). Items ranged from 0 (none) to 6 (cannot do) and were summed to a total score (0–72); higher scores indicating higher pre-injury or 90-day disability. Internal consistency was excellent (α = .96).

Baseline Covariates.

The baseline survey within 24-hours post-injury included additional measures such as current pain intensity in the ED (0–10), perceived life threat (yes/no), and existence of pre-injury chronic pain that participants experienced on a daily basis (yes/no). Additionally, patient injury severity scores (standardized anatomical scoring system of all traumatic injuries sustained by a patient, ranging from 1–75 by increasing injury severity (Baker et al., 1974), demographics (age, sex, race), insurance status (yes/no), and hospital admission status after injury (yes/no) were extracted through electronic medical record review.

Statistical Analysis.

Statistical analyses were performed using SPSS v. 28. Pearson correlation coefficients and one-way ANOVAs examined associations among baseline, 30-day, and 90-day variables and participant characteristics (e.g., group assignment, sex, and race). Although no significant differences emerged between intervention group assignment and study variables (Table S1), we still adjusted for group assignments in the mediation analyses. Prior to analysis, assumptions of linear regression were evaluated (e.g., linearity, normality of residuals, homoscedasticity, independence of errors), which indicated no substantial violations. Variance inflation factors were within acceptable ranges (all < 5.0). Mediation analyses were conducted using Preacher and Hayes’ PROCESS macro (IBM Corp.), a regression-based bootstrapping approach to estimate direct (c’) and indirect (a*b) effects using 10,000 resamples (Hayes, 2022). Statistical significance of reported unstandardized estimates were determined by 95% bootstrap confidence intervals not containing zero. First, we conducted two separate models to examine only each individual mediator. Then, we conducted a parallel mediation model to examine if effects were attributable to shared variance between the constructs. This approach may help address potential redundancy and inflation of Type I error from correlated mediators. Post-hoc power analyses in G*Power (Faul et al., 2007) suggests that power needed to detect the indirect effects for PC decreased from .780 in the separate models to only .496 in a parallel model. Final models adjusted for age, sex, group assignment, pre-injury chronic pain, and pre-injury disability; the disability outcome therefore reflects change in disability from pre- to post-injury.

Results

Primary Analysis.

A total of 47 participants completed all three assessments. Average age was 37.23 years (SD = 11.64), and most participants identified as female (63.8%) and non-White (61.7%). Mean pain intensity in the ED was 6.85 (SD = 1.97) on a 0–10 scale (Table S2). Mean injury severity score was 2.07 (SD = 1.44), while 30-day PC was 15.91 (SD = 15.87), 30-day PI was 20.78 (SD = 18.03), and 90-day disability was 17.20 (SD = 14.43). Higher ED pain was correlated with greater 30-day PI (r = .36, p < .01), PC (r = .40, p < .01), and 90-day disability (r = .36, p < .05). 30-day PI and PC were correlated with one another (r = .79, p < .01), and both were correlated with disability (PI: r = .76, p < .01; PC: r = .74, p < .01) (Table S3).

Mediation Analysis.

For the PC only mediation mode, paths a (effect = 2.15 [0.35 to 4.45]) and b (effect = 0.58 [0.38 to 0.79]) were significant (Table 1). The indirect effect was significant (effect = 1.24 [0.20 to 2.66]), while the direct effect was not significant (effect = −0.58 [−1.79 to 1.75]). This suggests that the relationship between ED pain and disability may be partially explained through effects of PC. For the PI only mediation model, paths a (effect = 2.67 [0.33 to 5.49]) and b (effect = 0.54 [0.37 to 0.68]) were significant. There was a statistically significant indirect effect (effect = 1.46 [0.20 to 2.95]), while the direct effect was not significant (effect = 0.02 [−1.45 to 1.60]). These results suggest that the relationship between ED pain and disability may be partially explained through effects of PI. In the combined parallel mediation model, neither PC (effect = 0.48 [−0.15, 1.47]) nor PI (effect = 1.03 [−0.02, 2.26]) had significant indirect effects alone. However, the combined indirect effect of both mediators was statistically significant (effect = 1.51 [0.03, 2.98]), which might indicate that a combined joint pathway exists.

Table 1.

The Effects of 30-day Cognitive Appraisal Processes as Mediators of Acute Pain and 90-day Disability (N = 47)

Mediator Effect Type Effect Size (Standard Error) 95% Confidence Interval
Pain Catastrophizing
X → M (a) 2.15 (1.04) 0.35, 4.45*
M → Y (b) 0.58 (0.10) 0.38, 0.79*
Indirect effect (ab) 1.58 (0.59) 0.56, 2.85*
Direct effect (c’) −0.58 (0.90) −1.79, 1.75
Perceived Injustice
X → M (a) 2.67 (1.33) 0.33, 5.49*
M → Y (b) 0.55 (0.78) 0.37, 0.68*
Indirect effect (ab) 1.46 (0.70) 0.20, 2.95*
Direct effect (c’) 0.02 (0.76) −1.45, 1.60
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Note.

*

Effects were considered significant if 95% confidence interval excluded zero. Two separate models were conducted. Both models adjusted for the covariates of age, sex, group assignment, pre-injury chronic pain, and disability from the 30-days pre-injury. The direct effect included only the singular path between acute pain intensity and 90-day disability. The indirect effect included the cumulative effects between acute pain intensity and 90-day disability through 30-day perceived injustice or pain catastrophizing.

Discussion

In separate mediation models, we identified PI and PC as potential mediators between acute pain and 90-day disability in adult ED patients with mild MVC injuries. Despite mild injury severity, average 90-day disability corresponded to moderate impairment (Üstün et al., 2010). In the combined parallel mediation model, the total indirect effect remained significant, whereas each individual indirect effect was attenuated. This suggests that these mediators might reflect a shared cognitive-affective pathway linking acute pain to long-term disability rather than fully distinct mechanisms. Additionally, consistent with the limited power suggested by the post-hoc power analyses, these inconsistent results may be due in part to small sample size, as it requires a large sample size to detect an effect in a multiple mediator model with substantial collinearity. However, this suggests that psychological processes may be involved in transitions from acute pain to long-term disability, consistent with prior research in patients with chronic back pain (Besen et al., 2017) and spinal cord injuries (Ullrich et al., 2007).

Both pain intensity and pain-related appraisal processes may be dynamic and potentially modifiable factors that might change across time and contexts following an injury (Bhatia et al., 2021). Early identification of problematic appraisal processes might allow for earlier psychological intervention to reduce the likelihood that acute pain develops into persistent disability (Sullivan et al., 2009). Specifically, prior research suggests that reductions in PC mediated relationships between physical therapy interventions and 90-day disability in chronic pain populations (Sisco-Taylor et al., 2022). Although research on PI as a modifiable target remains more limited than PC, reductions in PI have previously been associated with improved long-term outcomes (e.g., one year later) following injury and surgery (Yakobov et al., 2018).

Accessible, scalable, yet brief digital health interventions targeting PC and PI may aid in recovery and decrease disability. In outpatients with chronic pain, digital health interventions led to reduced PC (Bhatia et al., 2021) and improved emotional outlook on pain (Irvine et al., 2015). Given our small sample size, adequately powered longitudinal studies are needed to replicate findings and determine the relative contribution of PC and PI to inform intervention strategies.

This current sample was predominantly female and non-White race, which is consistent with the demographic characteristics reported in a larger multicenter cohort of MVC-related injury patients from 23 EDs across the U.S. (Beaudoin et al., 2021). However, our study was a longitudinally retained cohort, which may limit generalizability to the broader ED population of post-MVC patients, particularly those less likely to engage with follow-up surveys for 90 days.

Other limitations include the small sample size and high-risk inclusion criteria which may limit generalizability. Therefore, effect sizes may be smaller in a sample at lower risk for PTSD and chronic pain. Given the small sample, the absence of significant direct associations should not be interpreted as complete mediation. The findings instead support the possibility of indirect effects. Additionally, models did not control for baseline PC and PI, so it is unknown if they were pre-existing or developed in response to the MVC-related injury. Although the data were drawn from a null clinical trial, no significant differences emerged between group assignment and ED pain score, 30-day PI, 30-day PC, or 90-day disability. Additionally, app utilization was limited, with only two-thirds of participants reporting any engagement with the study intervention (Pacella et al, 2020), minimizing the likelihood that the app significantly influenced the relationships. Recall bias of pre-injury disability after injury was also possible, though these concerns were reduced by anchoring the pre-injury disability question to the 30 days pre-injury.

Despite limitations, these preliminary findings extend prior work and identified PC and PI as potential mediators between acute pain and future disability within ED patients after an MVC.

Supplementary Material

SupMat

Impact.

  • To our knowledge, this is the first study to identify psychological mediators between acute pain and 90-day disability in patients that sustained motor vehicle-related injuries.

  • Psychological processes are involved in transition from acute pain to long-term disability.

  • Early identification of problematic appraisal processes might allow for deployment of psychological interventions to prevent transition from acute pain to long-term disability.

Acknowledgments

This work was supported by the Virginia Kaufman Endowment Fund; University of Pittsburgh Clinical and Translational Science Institute (Pain Research Challenge Award 2017); National Institute of Arthritis and Musculoskeletal Skin Diseases (1K01AR073300-01A1); National Institute on Drug Abuse (1F31DA062393-01). Authors report no conflicts of interests.

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