An Holistic Approach to Wound Pain in Patients with Chronic Wounds

Author(s): 
Patricia Price, BA(Hons), PhD, AFBPsS, CH Psychol

I n recent years, there has been growing evidence that the experience of living with a chronic wound has a significant impact on a patient’s quality of life.1,2 A consistent finding, particularly in the qualitative work that has been completed, is that pain is a symptom patients find particularly distressing.3–5
A recent Canadian study6 suggests that the prevalence of pain in patients with pure or mixed venous ulcers is approximately 50%, with over 50% of these using analgesia as part of their treatment. Similar figures have been reported in other studies of leg ulceration.7–9 Health professionals are now starting to recognize the importance of addressing the issue of wound pain, as evidenced by the recent European Wound Management Association Position Document10 on pain, a supplement to Ostomy Wound Management dedicated to this topic (April 2003), and the consensus document on minimizing pain during wound dressing-related procedures launched at the World Union of Wound Healing Societies meeting.11
Pain is a personal issue, and there is little debate that pain is undeniably subjective. Early pain research emphasized the mechanical nature of pain, such as the withdrawal of the relevant body part from the noxious stimulus as a result of nerve action.12 However, the Gate Theory13 finally acknowledged the role of brain processes in pain perception that helped explain how injured athletes can continue to compete without noticing pain, while raised anxiety can result in the experience of pain without any apparent injury. The integration of the physiological and psychological aspects of pain in a single model mirrors the broader change in clinical practice that is moving away from a purely medical approach and toward holistic patient care.
Although only limited work has been completed on pain in chronic wounds, much of the research has focused on pain at dressing change. Indeed, in a recent multinational survey, practitioners consistently rated dressing removal as the time of greatest pain.14 In many ways, it is understandable why this should be the initial point of interest. Given that patients with leg ulcers are usually elderly with particularly fragile skin, the removal of dressings that stick to the wound may be the most painful part of the dressing procedure.15 Additionally, the potential impact of dressings on the surrounding skin drives manufacturers to produce dressings that are painless to remove with little or no impact on the surrounding tissues—an endeavor that should be applauded. One way manufacturers are attempting to limit the potential for pain upon dressing removal is by reducing adhesive mass on dressings.
However, within the framework of holistic care, clinicians must place the dressing change within the context of total pain management. Indeed, dressing changes represent only 1 type of wound-based pain within Krasner’s model of chronic wound pain.16 Krasner calls this type of pain “cyclic acute wound pain,” as it accompanies regular procedures performed by the health practitioner. A benefit of using dressings with longer wear times is that the wound can remain undisturbed for a longer period of time, extending the time between potentially painful cyclic events.
The other 2 components of the chronic wound pain model are non-cyclic acute wound pain, which occurs during intermittent manipulation of the wound, such as debridement, and chronic wound pain, which is persistent pain that is experienced even when the wound is not being manipulated. Clinicians must not forget persistent pain when evaluating treatment regimens for wound pain, because this type of pain has been highlighted by qualitative work as distressing to patients.

References: 

References

1. Franks PJ, Moffatt CJ, et al. Community leg ulcer clinics: effect on quality of life. Phlebology. 1994;9:83–86.
2. Price P, Harding KG. Measuring health-related quality of life in patients with chronic leg ulcers. Wounds. 1996;8(3):91–94.
3. Charles H. The impact of leg ulcers on patients’ quality of life. Prof Nurse. 1995;10(9):571–574.
4. Ebbeskog B, Ekman SL. Elderly people’s experiences. The meaning of living with venous leg ulcer. J EWMA. 2001;1(1):21–23.
5. Rich A, McLachlan L. How living with a leg ulcer affects people’s daily life: a nurse-led study. J Wound Care. 2003;12(2):51–54.
6. Nemeth KA, Harrison MB, Graham ID, Burke S. Pain in pure and mixed aetiology venous leg ulcers: a three phase point prevalence study. J Wound Care. 2003;12(9):336–340.
7. Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol. 1994;31(1):49–53.
8. Hofman D, Ryan T, Arnold F, et al. Pain in venous leg ulcers. J Wound Care. 1997;6(5):222–224.
9. Noonan L, Burge S. Venous leg ulcers: is pain a problem? Phlebology. 1998;13:14–19.
10. European Wound Management Association. Pain at Wound Dressing Changes. London, UK: Medical Education Partnerships LTD, 2002.
11. World Union of Wound Healing Societies. Principles of Best Practise: Minimising Pain at Wound Dressing-Related Procedures: A Consensus Document. London, UK: Medical Education Partnerships LTD, 2004.
12. Horn S, Munafo M. Pain: Theory Research and Intervention. London, UK: Open University Press, 1998.
13. Melzack R, Wall P. The Challenge of Pain. Harmondsworth, UK: Penguin, 1982.
14. Moffatt CJ, Franks PJ, Hollinworth H, et al. Understanding wound pain and trauma: an international perspective. In: Pain at Wound Dressing Changes. London, UK: Medical Education Partnerships LTD, 2002:2–7.
15. Briggs M, Bou TJ. Pain at wound dressing changes: a guide to management. In: Pain at Wound Dressing Changes. London, UK: Medical Education Partnerships LTD, 2002:12–17.
16. Krasner D. Caring for the person experiencing chronic wound pain. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, PA: HMP Publications, 2001.
17. Reddy M, Kohr R, Queen D, Keast D, Sibbald RG. Practical treatment of wound pain and trauma: a patient-centered approach. An overview. Ostomy Wound Manage. 2003;49(Suppl 4A):2–15.
18. World Health Organization. Cancer Pain Relief. Geneva, Switzerland: WHO, 1996.
19. Ferrell B. Patient education and non-drug interventions. In: Ferrell B, et al., eds. Pain in the Elderly. Seattle, WA: IASP Press, 1996.



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