Pain and the Journey of the Chronic Wound Patient

Hello everyone, and welcome back to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the assistant editorial director for Podiatry Today. And we're so happy to have Dr. Windy Cole joining us again as our guest as part of a two episode series on the chronic wound care patient experience. She's the director of Wound Care Research at Kent State University College of Podiatric Medicine, and the Global Medical Affairs Director for Natrox Wound Care. So in a recent podcast, we previously discussed the chronic wound patient journey. It was mentioned that pain associated with chronic wounds is one of the symptoms that patients find particularly distressing. Can you elaborate on this for our listeners?

Windy Cole, DPM:

Yeah. Sadly, chronic wounds cause decreased functional ability and a decrease in quality of life for up to 3% of individuals 60 years or older. So the healing process of a chronic wound can take many, many months, sometimes six to eight months or longer. I've treated patients that have lived with wounds, chronic, for 15 years or more. The prevalence of pain with chronic wounds has been estimated to be as high as 81%, with up to 50% of those patients reporting moderate to severe pain. So pain is a major factor when determining patient's quality of life. Did you know that quality of life is a predictor of major amputations and deaths for patients who experience mobility restrictions, self-care deficits, and inability to perform usual daily activities, and even those with uncontrolled pain. So there's definitely a relationship here that's worth investigating, and improving the patient journey. Increasing this quality of life for patients suffering with chronic wounds is really vital to improve our patient outcomes.

Jennifer Spector, DPM:

It absolutely seems like it is. So how is chronic wound pain typically managed?

Windy Cole, DPM:

Well, there's a lot of room for improvement here. The World Health Organization has an analgesic dosing ladder, and we often apply this for wound pain management. This ladder employs a scale that recommends treatment based on pain severity. So you would start with nonsteroidal anti-inflammatory drugs for those having mild pain scores between one and three, then possibly work up to an additional weak opioid analgesic for moderate pain scores, those patients with pain from a level four to six. And then they recommend replacing weak opioids with strong opioid analgesics for pain scores anywhere between seven and ten. But to date, we know that opioid addiction remains at epidemic levels in the US, and really worldwide. The United States accounts for about 80% of all opioid consumption in the world. And opioids are still being commonly prescribed for chronic wound pain, but I think we can do better. Not only are opioids addictive, they also can negatively impact tissue repair. Narcotic medications reduce immune system activation, decrease endothelial proliferation, impact tissue oxygenation, and also can alter fibroblast recruitment and impact kerat inocyte dysfunction, so they can actually contribute to wound chronicity.

Jennifer Spector, DPM:

I think a lot of clinicians aren't truly aware of that. So in your experience, are there alternative ways to support wound healing and decrease that wound pain?

Windy Cole, DPM:

Yeah, wound repair and tissue regeneration is heavily reliant on the presence of adequate oxygen levels within the injured tissues. So we know that oxygen is essential to multiple wound healing processes, including oxidative killing of bacteria, cellular signaling and proliferation, collagen deposition and angiogenesis. But despite this critical need for oxygen levels are often insufficient in patients with chronic wounds because they have a variety of systemic diseases like diabetes, which causes poor circulation, inactivation of growth factors, and then cellular senescence. Low levels of oxygen in the wounded tissues will then prolong healing and cause physical symptoms such as chronic wound pain.

I have been using topical oxygen therapy for wound management in my clinical practice for the last four years. And anecdotally, my patients have reported significant decreases in their wound pain upon initiation of topical oxygen therapy. There was also a recently published manuscript where the investigators found that utilization of topical oxygen to treat chronic venous leg ulcers contributed to a 76% reduction in substantial patient pain. This was a patient retrospective analysis of 20 patients, it was a pilot study. And they also reported that 69% of patients stopped opioid use altogether, while 53% of the patients in the study had complete resolution of all pain symptoms while using topical oxygen therapy.

While we don't really know the exact mechanism of action yet, this initial trial illustrates the potential of topical oxygen therapy as a treatment option to support not only wound healing, but also chronic wound pain management. We need larger studies so that we can learn more. But I'll tell you in my clinical practice and experience and seeing some of this mounting evidence, I'm intrigued about the possibility of topical oxygen therapy to be a game changer for patients suffering from chronic wound pain.

Jennifer Spector, DPM:

As always, your insights are greatly appreciated, Dr. Cole. Hopefully the listeners will take a look at their own pain management practices in wound care with a new lens. To listen to Dr. Cole's first episode in this series, along with all other episodes, head over to podiatrytoday.com or your favorite podcast platforms.