An Holistic Approach to Wound Pain in Patients with Chronic Wounds

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. In addition to dressings, there are other key aspects of care that the practitioner should consider, starting with identifying the cause of pain (if possible). Little doubt exists that wound infection and inflammation can be painful, and treatment to reduce infection will result in pain reduction or even elimination.¹⁷ For some patients, the use of appropriate compression can result in reduced pain, once the edema is under control. Many patients use analgesia as part of their treatment. As many as 75% of patients find this helpful.⁶ The analgesic ladder from the World Health Organization is a useful guide for the strength and dose of analgesia.¹⁸ Studies have shown that these pharmacological interventions are more effective if they are coupled with other interventions, such as patient education about expectations of pain or learned coping strategies.¹⁹ Within wound care management, clinicians must be careful to ensure that the patient is the focal point of care, with all aspects of pain management considered within a package of care that reflects a move away from considering the “wound” to considering the “person.”