Chronic pain among UK ex-Service personnel: Is there a need to know and do more?
To date, little is known about the prevalence and impact of chronic pain among United Kingdom (UK) ex-Service personnel. Evidence from the United States (US) and Canada, however, indicates that this might be an area for needed attention. In this news feature we provide an overview of the limited available UK evidence and highlight why it is important to understand more about chronic pain among UK ex-Service personnel.
Chronic pain and the unique risk profile for ex-Service personnel
Chronic pain is typically defined as pain that lasts either longer than three months or longer than the typical healing time for an injury [1]. But there is more to set apart chronic pain from acute pain than duration alone. While the exact causes of chronic pain remain poorly understood, evidence suggests it is a complex condition influenced by psychological and social as well as physical and biological factors [2, 3]. In some cases, chronic pain can persist without an identifiable physical or biological cause [4].
Considering the potential unique risk profile for chronic pain among ex-Service personnel, it is important to consider that chronic pain is among the primary symptoms of musculoskeletal injury. Musculoskeletal disorders and injuries (MDI) are consistently reported as one of the most common causes for medical discharge from the UK [5], US [6], and Canadian Armed Forces [7].
Despite this association and therefore risk of chronic pain among ex-Service personnel, the UK does not currently track the prevalence of chronic pain among ex-Service personnel in an official or centralised manner. In the US and Canada, due to their respective Veterans Affairs Departments, they are able to directly track the incidence of chronic pain in ex-Service personnel, with data indicating it is more prevalent among US ex-Service personnel (20-30%) [8, 9] than the US general population (20.9%) [10], and even higher rates (41%) are reported among Canadian ex-Service personnel [11]. That MDI are among the most common reasons for medical discharge from the UK Armed Forces, alongside the high prevalence rate of chronic pain among ex-Service personnel from the US and Canada, raises the possibility that chronic pain could be more prevalent among UK ex-Service personnel, compared to the general population.
What we know about chronic pain among UK ex-Service personnel
While data about the prevalence of chronic pain among UK ex-Service personnel is unavailable, evidence from the limited available UK research suggests there is cause for a better understanding of impact and care needs, as well as prevalence. Emerging evidence indicates that ex-Service personnel may experience chronic pain differently than the general population because of how their time in the Armed Forces taught them to relate to their bodies [12]. This is consistent with research that has indicated that UK ex-Service personnel cope with chronic pain in a distinctive way, drawing on their military background in coping with their pain experiences [13]. Additionally, chronic pain can seemingly complicate transitioning from the Armed Forces into civilian society, with ex-Service personnel with chronic pain reporting that their pain can be a complicating factor when finding employment [14]. Finally, chronic pain has been found to be associated with higher rates of Post-Traumatic Stress Disorder (PTSD), anxiety, and depression among a cohort of UK ex-Service personnel seriously injured in Afghanistan [15]. Since recent evidence indicates that rates of PTSD among UK ex-Service personnel have risen in recent years [16], these findings suggest that further research on chronic pain among UK ex-Service personnel more generally is desirable.
Chronic pain, PTSD, sleep, and moral injury
Evidence from the US suggests that ex-Service personnel experiencing both PTSD and chronic pain report greater pain severity than those with chronic pain alone [17]. Additionally, evidence from a meta-review of 477 academic papers that discuss chronic pain and PTSD suggests that the two conditions are correlated, meaning that those who have PTSD are more likely to also have chronic pain and vice versa [18]. Both PTSD and chronic pain can involve attentional biases, making those that experience the conditions more likely to attend to, anticipate, and overestimate negative experiences such as anxiety and pain [19]. Similarly, given that PTSD typically involves high levels of anxiety, and evidence from the Canadian context suggests that pain-related anxiety can worsen the perception of pain [20], the comorbidity of PTSD with anxiety could lead to a vicious circle in which symptoms of PTSD worsen the symptoms of chronic pain which, in turn, worsen the symptoms of PTSD.
Similar evidence exists concerning the relationship between chronic pain and sleep disorders, such that the quality of sleep not only affects the perception of pain, but that sleep disorders can substantially worsen the symptoms of chronic pain [21, 22]. Patients who report both sleep disorders and chronic pain have been found to report greater intensity and increased duration of pain, greater disability, and increased difficulties with physical activity compared to those who report chronic pain alone [23]. Additionally, there is evidence that sleep disorders are associated with increased incidence rates of combat-related PTSD, chronic pain, and anxiety disorders respectively [24, 25, 26]. Since UK research provides emerging evidence that PTSD and common mental disorders are reported at higher rates among UK ex-Service personnel who served during the Iraq and Afghanistan era compared to the general population [27], and considering the potential connection between PTSD and chronic, there is further evidence of a need to better understand chronic pain among the UK ex-Service population.
Finally, emerging evidence suggests a connection between moral injury and chronic pain in US ex-Service personnel. Moral injury, which occurs when someone experiences a traumatic event that is at odds with deeply held moral principles, can worsen chronic pain, particularly in women [28]. Moral injury is associated with strong feelings of guilt and shame, which can exacerbate both symptoms of PTSD and chronic pain [29]. Evidence concerning moral injury among UK ex-Service personnel supports this idea and suggests a strong association between experiences of moral injury and adverse mental health outcomes associated with chronic pain, such as PTSD and anxiety [30]. This again shows the complex nature of chronic pain, and how a person’s beliefs about their pain can influence their experience of it.
The importance of multidisciplinary care
Clinical practice for US ex-Service personnel experiencing chronic pain has already adjusted to reflect the blend of psychological and physical factors often reported. The US Department of Veterans Affairs (VA) pain rehabilitation programmes have shifted from fragmented care, where patients are treated for their pain by different specialists separately, to an integrated model in which patients with chronic pain receive multidisciplinary treatment [31]. In this integrated model, patients receive care not only from physicians, but from psychologists, pharmacists, and nurses with specific training, all of whom are guaranteed to have some understanding of military culture and jointly coordinate the care provided [32]. All evidence points toward the conclusion that this integrated model is more effective in the treatment and management of chronic pain than a fragmentary model, with marked decreases in pain intensity, improvements in mobility, and sleep disorders when compared to fragmented care [33]. Indeed, evidence from multidisciplinary pain treatment programmes in the Canadian context further suggests that ex-Service personnel dealing with chronic pain may benefit even more from multidisciplinary treatment than members of the general population [34].
But this is not all: the same US evidence suggests that integrated care strongly decreases the incidence of a key psychological component of chronic pain: pain catastrophising, which decreased by 31% among those who received the multidisciplinary VA treatment [33]. Pain catastrophising refers to a tendency among those who experience chronic pain to ruminate about and overestimate their pain, and feel hopeless about their situation [35]. According to available evidence, pain catastrophising plays an important role in worsening chronic pain conditions as well as in making those conditions particularly disabling, with the fear of pain preventing those with chronic pain from engaging in physical activities they otherwise might [36]. Because of this, the decrease in pain catastrophising among those treated for chronic pain by the VA according to the multidisciplinary scheme is particularly noteworthy: not just because pain catastrophising can play a role in sustaining chronic pain, but because managing pain catastrophising can help to make chronic pain a less disabling condition.
These findings from the clinical context fit with the idea that psychological factors play an important role in both the causes of chronic pain disorders and in the extent to which they are disabling. Pain catastrophising, depression, anxiety, sleep disorders, and PTSD, all interact with chronic pain in complex ways, potentially worsening the chronic pain and being worsened by it in turn. Given that available evidence suggests above average incidence rates of mental health conditions among UK ex-Service personnel [27], it follows that they may be at higher risk of more severe chronic pain disorders than the general public. However, this is yet to be investigated in the UK and raises an important area of needed research.
The way forward: policy and research suggestions
The presented evidence provides a compelling case for the need for additional research. While the US, Canadian, and UK Armed Forces are comparable in some ways, they are not identical. Rather than assuming that the experience of ex-Service personnel in the US and Canada is representative of the experiences of UK ex-Service personnel, it is important that data be gathered about UK ex-Service personnel to determine whether they experience chronic pain differently and therefore have different needs. For example, while there is evidence for a correlation between PTSD and chronic pain in US ex-Service personnel, the absence of data concerning chronic pain among UK ex-Service personnel means that there is currently no way of determining whether the same is true in the UK context [37].
The Veterans’ Strategy Action Plan: 2022 to 2024 includes plans to roll out a standard Veteran marker across government departments, with the aim of making it easier to see what sort of care and services are being accessed by former members of the Armed Forces [38], which may enhance the ability to conduct needed research and have a clearer picture of prevalence and need. But this remains a work in progress and any quantitative data must also be enriched with qualitative research about the experience of chronic pain in order to ensure that the specific needs of the ex-Service population are properly understood.
Identifying ex-Service personnel poses another key challenge, due to the unique needs of ex-Service personnel when compared to the general population [13]. There is evidence that awareness of military culture and training for primary caregivers on detecting traumas in ex-Service personnel is particularly helpful in overcoming this difficulty [39]. The recent push for GPs to become more ‘Veteran friendly’ as part of the Military Veteran Aware Accreditation scheme is encouraging in this respect [40]. As part of the requirements for the accreditation, both the clinical and administrative staff of GP practices undertake additional training to better understand the health needs of ex-Service personnel and military culture, as well as put in place a system for identifying and flagging ex-Service personnel within the GP practice. This accreditation is likely to prove key in assisting UK ex-Service personnel dealing with chronic pain, as there is strong evidence to suggest that early detection and treatment of chronic pain can help prevent the development of comorbid conditions which, as already discussed, can serve to complicate chronic pain conditions in various ways [41].
However, US evidence indicates that effective treatment of chronic pain in ex-Service personnel is more likely to require a multifaceted and integrated approach in order to be maximally effective, combining physical and psychological therapy. While much of the care provided to the UK general public experiencing chronic pain via the NHS is already multidisciplinary, with pain management teams made up of anaesthetists, psychologists, and specially trained physiotherapists in addition to other staff, how this translates to the needs of the ex-military community is yet to be determined.
Focused research to address the identified gaps including prevalence, risk factors, the role of co-occurring conditions and other factors in trajectory, as well as care preferences and priorities is needed. Without further research, UK ex-Service personnel may struggle with chronic pain in silence or receive inadequate care; a risk that is all the graver precisely because chronic pain can worsen so many other conditions.
Many thanks to Dr Dominic Aldington for his expert review of this news feature.
References
[1]. Treede, R.D., Winfried, R., Antonia, B., Qasim, A., Bennett, M.I., Benoliel, R., et al. (2015). ‘A classification of chronic pain for ICD-11’ Pain 156(6), 1003-1007. Available at: (link)
[2]. Dansie, E.J. & Turk, D.C. (2013). ‘Assessment of patients with chronic pain’ British Journal of Anaesthesia 111(1), 19-25. Available at: (link)
[3]. Raffaeli, W., Tenti, M., Corraro, A., Malafoglia, V., Ilari, S. Balzani, E. & Bonci, A. (2021). Chronic pain: What does it mean? A review of the use of the term chronic pain in clinical practice. Journal of Pain Research, 14, 827-835. Available at: (link)
[4]. Loeser, J.D. (1991). ‘What is chronic pain?’, Thereotical Medicine, 12, 213-225. Available at: (link)
[5]. Ministry of Defence, 2024. ‘UK service personnel medical discharges: financial year 2023/24’. Ministry of Defence. Available at: (link)
[6]. Molloy, J.M., Pendergrass, T.L., Lee, I.E., Chervak, M.C., Hauret & K.G., Rhon, D.I. (2020). ‘Musculoskeletal Injuries and United States Army Readiness Part I: Overview of Injuries and Strategic Impact’. Military Medicine, 185(9-10), 1461-1471. Available at: (link)
[7]. Serré, L. (2019). ‘A comparative analysis of medically released men and women from the Canadian Armed Forces’, Journal of Military, Veteran and Family Health, 5(2), 115-124. Available at: (link)
[8]. Qureshi, A.R., Patel, M., Neumark, S., Wang, L., Couban, R.J., Sadeghirad, B., Bengizi, A. & Busse, J.W. (2023). ‘Prevalence of chronic non-cancer pain among military veterans: a systematic review and meta-analysis of observational studies’ BMJ Military Health. Available at: (link)
[9]. Taylor, K.A., Kapos, F.P., Sharpe, J.A., Kosinski, A.S., Rhon, D.I. & Goode, A.P. (2024). ‘Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans’, The Journal of Pain, 25(5). Available at: (link)
[10]. Rikard, M.S., Strahan, A.E., Schmit, K.M., Guy, G.P. (2023). ‘Chronic Pain Among Adults – United States, 2019-2021’. Morbidity and Mortality Weekly Report, 72(15), 379-385. Available at: (link)
[11]. Velez, J.R., Thompson, J.M., Sweet, J., Busse, J.W. & VanTil, L. (2021). ‘Cluster analysis of Canadian Armed Forces veterans living with chronic pain: Life After Service Studies 2016.’ Canadian Journal of Pain 5(1) 81-95. Available at: (link)
[12]. Kersey, T.D. (2022). Narratives of Chronic Pain from Armed Forces Veterans. PhD thesis. Available at: (link)
[13]. Hitch, C., Harper, B., Waterhouse-Bradley, B. & Armour, C. (2020). ‘How Army Veterans Cope with Chronic Pain: A Grounded Theory Approach’. Journal of Veterans Studies, 6(1), 122-134. Available at: (link)
[14]. Hynes, C., Scullion, L., Lawler, C., Steel, R. & Boland, P. (2022). Lives in Transition: returning to civilian life with a physical injury or condition. Available at: (link)
[15]. Vollert, J., Kumar, A., Coady, E.C., Cullinan, P., Dyball, D., Fear, N.T, Gan, Z., Miller, E.F., Sprinckmoller, S., Schofield, S., Bennett, A., Bull, A.M.J., Boos, C.J., Rice, A.C.S. & Kemp, H.I. (2024). ‘Pain after combat injury in male UK military personnel deployed to Afghanistan’, British Journal of Anaesthesia, 132(6), 1285-1292. Available at: (link)
[16]. Sharp, M.L., Franchini, S., Jones, M., Leal, R., Wessely, S., Stevelink, S.A.M. & Fear, N.T. (2024). ‘Health and Wellbeing Study of Serving and ex-Serving UK Armed Forces Personnel: Phase 4’. King’s College Military Health. Available at: (link)
[17]. Morasco, B.J., Lovejoy, T.I., Lu, M., Turk, D.C., Lewis, L. & Dobscha, S.K. (2013). ‘The relationship between PTSD and chronic pain: Mediating role of coping strategies and depression’. Pain, 154(4), 609-616. Available at: (link)
[18]. Fishbain, D.A., Pulikal, A., Lewis, J.E. & Gao, J. (2017). ‘Chronic Pain Types Differ in Their Reported Prevalence of Post-Traumatic Stress Disorder (PTSD) and There Is Consistent Evidence That Chronic Pain Is Associated with PTSD: An Evidence-Based Structured Systematic Review’, Pain Medicine, 18(4), 711-735. Available at: (link)
[19]. Sharp, T.J. & Harvey, A.G. (2001). ‘Chronic Pain and Posttraumatic Stress Disorder: Mutual Maintenance?’. Clinical Psychology Review, 21(6), 857-877. Available at: (link)
[20]. Thibodeau, M.A., Welch, P.G., Katz, J. & Asmundson, J.G. (2013). ‘Pain-related anxiety influences pain perception differently in men and women: A quantitative sensory test across thermal pain modalities.’ Pain, 154(3), 419-426. Available at: (link)
[21]. Lautenbacher, S., Kundermann, B. & Krieg, J.C. (2006). ‘Sleep deprivation and pain perception’. Sleep Medicine Reviews, 10(5), 357-369. Available at: (link)
[22]. Finan, P.H., Goodin, B.R. & Smith, M.T. (2013). ‘The Association of Sleep and Pain: An Update and a Path Forward’, The Journal of Pain, 14(12), 1539-1552. Available at: (link)
[23]. Husak, A.J. & Bair, M.J. (2020). ‘Chronic pain and sleep disturbances: a pragmatic review of their relationships, comorbidities, and treatments’. Pain Medicine, 21(6), 1142-1152. Available at: (link)
[24]. Van Liempt, S. (2012). ‘Sleep Disturbances and PTSD: a perceptual circle?’ European Journal of Psychotraumatology, 3(1). Available at: (link)
[25]. Mathias, J.L.., Cant, M.L. & Burke, A.L.J. (2018). ‘Sleep disturbances and sleep disorders in adults living with chronic pain: a meta-analysis.’ Sleep Medicine, 52, 198-210. Available at: (link)
[26]. Cox, R.C. & Olatunji, B.O. (2016). ‘A systematic review of sleep disturbance in anxiety and related disorders.’ Journal of Anxiety Disorders, 37, 104-129. Available at: (link)
[27]. Rhead, R., MacManus, D., Jones, M., Greenberg, N. & Fear N.T. (2022). ‘Mental health disorders and alcohol misuse among UK military veterans and the general population: a comparison.’ Psychological Medicine, 52(2), 292-302. Available at: (link)
[28]. Ranney, R.M., Maguen, S., Bernhard, P.A., Holder, N., et al. (2022). ‘Moral injury and chronic pain in veterans’. Journal of Psychiatric Research, 155, 104-111. Available at: (link)
[29]. Morgan, L. & Aldington, D. (2021). ‘Chronic Pain, PTSD and Moral Injury in Military Veterans: Suffering and the Compromised Self’, 10(4), 267-274. Available at: (link)
[30]. Williamson, V., Murphy, D., Stevelink, S.A.M., Allen, S. et al. (2021). ‘The impact of moral injury on the wellbeing of UK military veterans’. BMC Psychology, 9(73), 1-7. Available at: (link)
[31]. Department of Veteran Affairs (2009). ‘VHA Directive 2009-053: Pain Management’. Department of Veterans Affairs, Washington, DC. Available at: (link)
[32]. Seal, K., Becker, W., Tighe, J. Li, Y. & Rife, T. (2017). ‘Managing Chronic Pain in Primary Care: It Really Does Take a Village’. Journal of General Internal Medicine, 32, 931-934. Available at: (link)
[33]. Murphy, J.L., Palyo, S.A., Schmidt, Z.S, Hollrah, L.N., Banou, E., Van Keuren, C.P. & Strigo, I.A. (2021). ‘The Resurrection of Interdisciplinary Pain Rehabilitation: Outcomes Across a Veterans Affairs Collaborative’. Pain Medicine, 22(2), 430-443. Available at: (link)
[34]. Jomy, J. & Hapidou, E.G. (2020). ‘Pain management program outcomes in veterans with chronic pain and comparison with nonveterans’, Canadian Journal of Pain, 4(1), 149-161. Available at: (link)
[35]. Quartana, P.J., Campbell, C.M. & Edwards, R.R. (2009). ‘Pain catastrophizing: a critical review’. Expert Review of Neurotherapeutics, 9(5), 745-758. Available at: (link)
[36]. Severeijns, R., Vlaeyen, J.W.S., Van Den Hout, M.A. & Weber, W.E.J. (2001). ‘Pain Catastrophizing Predicts Pain Intensity, Disability, and Psychological Distress Independent of the Level of Pain’. The Clinical Journal for Pain, 17(2), 165-172. Available at: (link)
[37]. Morgan, L. & Aldington, D. (2020). ‘Comorbid pain and post-traumatic stress disorder in UK veterans: a lot of theory but not enough evidence’. British Journal of Pain, 14(4), 256-262. Available at: (link)
[38]. Office for Veterans Affairs (OVA) (2022). ‘Veterans’ Strategy Action Plan: 2022 to 2024’. Available at: (link)
[39]. Gauntlett-Gilbert, J. & Wilson, S. (2013). ‘Veterans and chronic pain’. British Journal of Pain, 7(2), 79-84. Available at: (link)
[40]. NHS (2018). ‘GP practices across the country become ‘veteran friendly’’. National Healthservice. Available at: (link)
[41]. Sherbourne, C.D., Asch, S.M., Shugarman, L.R., Goebel, J.R., Lanto, A.B., Rubenstein, L.V. et al. (2009). ‘Early Identification of Co-Occurring Pain, Depression and Anxiety’. Journal of General Internal Medicine, 24, 620-625. Available at: (link)
