Understanding Pain and Quality of Life for Patients With Chronic Venous Ulcers

     Abstract: Aim. To identify the impact of pain on quality of life (QOL) of patients with chronic venous ulcers. Methods. A cross-sectional study was performed on 40 outpatients with chronic venous ulcers who were recruited at one outpatient care center in São Paulo, Brazil. WHOQOL-Bref was used to assess QOL, the McGill Pain Questionnaire-Short Form (MPQ) to identify pain characteristics, and an 11-point numerical pain rating scale to measure pain intensity. Kruskall-Wallis or ANOVA test, with post-hoc correction (Tukey test) was applied to compare groups. Multiple linear regression models were used. Results. The mean age of the patients was 67 ± 11 years (range, 39–95 years), and 26 (65%) were women. The prevalence of pain was 90%, with worst pain mean intensity of 6.2 ± 3.5. Severe pain was the most prevalent (21 patients, 52.5%). Pain most frequently reported was sensory-discriminative and evaluative in quality. Pain was significantly and negatively correlated with physical (PY), environmental (EV), and overall QOL. Compared to a no-pain group, those with pain had lower overall QOL. On multiple analyses, pain remained as a predictor of overall QOL (b = -0.73, P = 0.03) and was also predictive of social QOL, whereas pain did not have any impact on physical, emotional, or social relationships QOL (b = -3.85, P = 0.00) when adjusted for age, number, duration and frequency of wounds, pain dimension (MPQ), partnership, and economic status. Conclusion. To improve QOL of outpatients with chronic venous ulcers, the qualities and the intensity of pain must be considered differently.

Address correspondence to:
Vera Lúcia Santos, PhD
School of Nursing, University of São Paulo
Av. Dr. Enéas de Carvalho Aguiar
São Paulo 05403-000
Brazil
Phone: 55 1130 667 566
E-mail: veras@usp.br


     Leg ulcers are significantly prevalent in the general population (0.6 to 3.6/1000 people) and among patients with chronic wounds.¹ In Brazil, 55.1% of patients with chronic wounds presented venous ulcers (VU). ² The majority of these patients has or will have pain at some point. Some studies described that the prevalence of pain among these patients was about 48% to 90%,^3,4 and has been associated with impaired quality of life. ^5–7      Pain in individuals with venous ulcers, like in any other individual, is usually multidimensional and has multiple causes. It results not only from the injury itself and its treatment, but also from a set of factors. These factors include culture, beliefs, attitudes, individual values, secondary gains, and others. ⁸ In the 1960s, Melzack et al⁹ proposed that pain was not just a sensorial experience. He proposed that pain composed at least 3 dimensions: sensorial-discriminative, affective-motivational, and cognitive-evaluative, characterizing pain as a multidimensional experience.      Pain can cause social, familial, and personal losses, and can impact negatively on diverse domains of quality of life (QOL). Quality of life, like pain, is a multidimensional concept defined by the World Health Organization¹⁰ (WHO) as the individual perception of his or her position in life within the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. Although the impact of a wound on daily life can be viewed from different perspectives, only an individual with a wound can genuinely understand the meaning of such an experience. ¹¹      Quality of life for people with leg ulceration has been researched in some qualitative and quantitative studies. However, only some have investigated the relationship between QOL and pain. ^6,12 In Brazil, despite the high prevalence of venous ulcers (VU),13 no studies were found that assessed the impact of pain on the QOL of people with VU. Thus, the present study aimed to: 1) describe pain characteristics and QOL of patients with chronic venous ulcers (VU); 2) investigate whether QOL differs among patients with different levels of pain; 3) evaluate the correlations between pain and QOL; and 4) investigate whether impairment on dimensions of QOL was secondary to pain, demographic and economic characteristics, or to intrinsic factors related to wounds itself, such as frequency, number, and duration of the wound.

Patients and Methods

     A cross-sectional, descriptive study was performed after the Human Ethics Committee at the School of Nursing, University of Sao Paulo, Brazil approved the study. Between June and October 2006, 40 outpatients were recruited who had a previously diagnosed venous ulcer (VU). The patients were drawn from one outpatient setting, a university vascular surgery center located in São Paulo, Brazil. These patients had been treated with regular care procedures; topical therapy included wound cleansing with normal saline (0.9%) and papain solution (2%). In the presence of adherent slough, papain powder (100%) was also used. Gauze impregnated with papain (2%) was used as dressing. Hydrofiber dressing with silver was applied if infection was present. At home, patients were instructed to cleanse and wash their wound with drinking water. For edema control, an inelastic (Unna boot) or elastic compression bandage (one layer) was used for the initial and subsequent maintenance treatments, respectively. Patients were instructed to elevate the affected limb when supine or sitting. In the presence of infection, antibiotics were ordered. Patients were instructed to use oral non-opioid analgesics (eg, acetaminophen and dypirona) and nonsteroidal anti-inflammatory drugs (such as ibuprofen, naproxen, and cyclooxigenase-2 inhibitors) for pain control.      Patient assessment. Patients were assessed after undergoing ulcer cleansing. Their medical records were checked to verify previous chronic VU diagnosis. After the procedures and purpose of the study was explained to qualified patients, signed written informed consent was obtained to participate in the study. Patients completed the study instruments by interview. Some other clinical information was collected from the patient’s medical records. All the patients were examined by a single observer.      Inclusion criteria. Inclusion criteria were: older than 18 years; a VU present for more than 1 month; able to understand and speak Portuguese; and no signs of cognitive impairment. Patients who did not present these criteria, or had any painful neuropathic diseases (eg, diabetes) or another painful condition (eg, arthritis), were not eligible to participate in the study.      Measurements. The study instruments included a demographic and clinical questionnaire, the Brazilian short-form of the McGill Pain Questionnaire (SFMPQ), ¹⁴ the pain intensity numerical rating scale (PI-NRS), ¹⁵ the pain management index (PMI), ¹⁶ and the World Health Organization’s QOL instrument-abbreviated version (WHOQOL-Bref). ¹⁷      The demographic and clinical questionnaire included information about gender, age, monthly family income, marital status, educational level, religion, practice of religion, employment status, and others. The clinical information collected was number of VU, duration of VU, frequency of wounds (number of times patient had a VU), and others.      The Brazilian version of WHOQOL-Bref was used to assess QOL. The WHOQOL-Bref is a 26-item, cross-cultural, and self-administered scale that covers 4 domains of QOL (psychological, physical, social relationships, environmental). ¹⁷ Additionally, this instrument includes items to measure global health status and global quality-of-life that make up the overall quality-of-life component. The scores for all scales range from 0 to 100 and were calculated according to the instructions provided by the WHOQOL committee. ¹⁸ A higher score represents a higher (ie, “better”) quality of life. The WHOQOL-Bref has been used to measure the general QOL in healthy Brazilians. The validation process in Brazil is described elsewhere. ¹⁷      The WHOQOL-Bref was chosen as the QOL measure for the current study because it is relatively short and easy to administer. Additionally, it has established validity and reliability in the Brazilian population. In the sample, the WHOQOL-Bref showed satisfactory internal consistency (Cronbach’s alpha = 0.85). Cronbach’s alpha coefficients for each domain ranged from 0.45 to 0.85.      The Numeric Rating (pain) Scale (NRS)15 was used to assess worst pain, least pain, average pain, and present pain intensity. Each item was rated on an 11-point scale ranging from 0 (no pain) to 10 (pain as bad as you can imagine). Based on this scale, pain intensity was classified as mild (1–4), moderate (5–6), and severe (7–10) according to the optimal cut points identified by Serlin et al. ¹⁹ The PI-NRS was chosen as the pain measure for the present study because it showed a relevant degree of association with other pain scales, such as the visual analogue scale (VAS), verbal rating scale (VRS), and other non-numeric scales; ^14,20 therefore, supporting the option to use the 11-point PI-NRS. According to a Brazilian study developed with elderly people, the numerical rating scale was considered the easier and clearer pain scale compared to other unidimensional scales. ¹⁴      The qualities and characteristics of pain were assessed by the Brazilian short-form McGill Pain Questionnaire (SFMPQ). ¹⁴ This instrument was developed by Brazilian researchers based on the long-form McGill Pain Questionnaire (MPQ) developed by Melzack, ²¹ which was translated and validated in Brazil. ²² The MPQ consists of 3 major classes of word descriptors—sensory, affective, and evaluative—that are used by patients to specify a subjective pain experience. ²¹ The SFMPQ includes 30 pain descriptors that were grouped in 3 dimensions: sensorial-discriminative (items 1–14, 26, 27, and 28), affective-motivational (items 15–23, 29, and 30), and evaluative-cognitive (items 24 and 25). Two scores can be obtained from SFMPQ: the number of words chosen (NWC), with scores ranging from 0–30; and the percent of words chosen (PWC), with a threshold more than 30%, indicating that the descriptor is significant for a description of the pain in a specific group. In this study, both scores were calculated and the instrument proved to have regular internal consistency as assessed with Cronbach’s alpha for all 39 items (Cronbach’s alpha = 0.64). The SFMPQ was chosen as the pain quality measure for the current study because it is the only instrument available in Brazil to evaluate pain characteristics/qualities.      The adequacy of analgesic prescription was estimated by using the Pain Management Index (PMI), a measure for prescribing analgesics and an approximate measure of good pain treatment. This index is based on WHO guidelines. ²³ It compares the type of analgesic prescribed with the severity of a patient’s reported worst pain by subtracting the rating of the most potent analgesic agent (none = 0, nonopioid = 1, weak opioid = 2, or strong opioid = 3) prescribed for chronic pain from the patient’s rating of worst pain (none = 0, mild = 1–3, moderate = 4–7, or severe = 8–10). The PMI was computed by subtracting the pain level from the analgesic level (range, -3 to +3). Negative scores were considered as indicative of inadequate orders for analgesic drugs, and scores of 0 or higher were considered to be a conservative indicator of acceptable treatment. ¹⁶      Statistical analyses. Data were stored and analyzed using SPSS version 13.0 (SPSS Inc, Chicago, IL). Descriptive statistics were generated on the sample characteristics, pain variables, and QOL domains. Differences among patients with none (G1), mild (G2), moderate (G3), and severe (G4) pain were tested by Pearson’s chi-squared test in cases of categorical data, and by Kruskal-Wallis or ANOVA tests in cases of continuous data. The choice between these last two tests was made after assessing the adherence to the normal distribution with the Kolmogorov-Smirnov test. They were followed by post-hoc analyses using the Tukey procedure to control the overall family alpha level of the 6 possible pairwise contrasts at 0.05. ²⁴ The P-value presented for each pairwise contrast was adjusted so that P < 0.05 indicated significance. Pearson or Spearman coefficients were used to establish correlations between QOL domains, and clinical and demographic characteristics. The magnitude of the correlation coefficients was classified as: weak, (< 0.3); moderate, (0.3–0.6); strong, (> 0.6–0.9); and perfect, (1.0). ²⁵      The Kolmogorov-Smirnov test indicated a normal distribution to the following continuous variables: physical (P = 0.93), psychological (P = 0.18), social relationships (P = 0.47), and environmental (P = 0.75). WHOQOL-Bref’s domains and overall QOL (P = 0.16); worst pain intensity (P = 0.24); age (P = 0.64); SFMPQ sensory (P = 0.44); and affective (P = 0.25) dimensions.      Multiple linear regressions were used to assess the impact of pain, and some clinical and demographic characteristics, on overall QOL and WHOQOL-Bref’s domains. In all models, the scores of the QOL domains were the dependent variables. In each of the models, the following variables were considered independent: age, gender, monthly family income, marital status, employment status, religion; present, worst, and least pain intensities; sensory, evaluative, and affective pain dimensions; number, frequency, and duration of VU. The multiple linear regression analyses were performed after uni-varied analyses, and included variables that had Wald’s test score of P ≤ 0.20. Multicollinearity and interaction among independent variables were assessed and were not identified. A stepwise, multivariate linear regression procedure was used to select variables in the QOL models.      In all analyses, P < 0.05 indicated significance. All statistical tests were two-sided.

Results

     Forty patients were enrolled. Of these, 36 reported pain (90%); it was mild in 8 (20%), moderate in 7 (17.5%), and severe in 21 (52.5%). These patients were compared in relation to their pain, clinical and demographic characteristics (Tables 1 and 2).      Patient characteristics. Table 1 summarizes the demographic characteristics for the total sample (N = 40) and for the 4 patients subgroups (none, mild, moderate, and severe pain). Of the 40 outpatients with VU in this study, two-thirds were women, and three-quarters (n = 30) studied up to the secondary school. Overall mean age was 67.7 years (range 39–95). It could not be tested if there were any significant differences (P < 0.05) among the 4 pain subgroups regarding demographic characteristics, because more than 20% of the data cells had an expected frequency of less than 5 patients, and some cells had an expected frequency of less than 1.      The pain patient subgroups were homogeneous in relation to wound aspects. The median number of wounds was 1 (range 1–8). This number was not statistically different among pain subgroups (P = 0.835). In the total sample, the median wound duration was 36 months (range = 1–576), and it was not significantly statistically different among pain subgroups (P = 0.269; Table 2).      The majority of wounds were located in medial malleolus (n = 25, 62%), lateral (n = 11, 27%), and tibial locations (n = 4, 11%). None of the wounds were located below malleolus. More than half (n = 26, 65%) of patients did not undergo any surgery to treat their VU. Those who underwent some surgical treatment, had surgical debridement (n = 7, 17.5%), grafting (n = 6, 15.0%), and sympathectomy (n = 1, 2.5%).      Pain characteristics. The mean (± SD) pain intensities for the worst, least, and present pains were 6.2 ± 3.5, 1.2 ± 2.3, and 3.5 ± 3.7, respectively. The mean percentage of pain descriptors chosen from the sensory, affective, and evaluative MPQ dimensions for patient subgroups were statistically different (P ≤ 0.001, 0.002, 0.001, respectively [Table 2]). A one-way ANOVA followed by a Tukey test confirmed that there were differences in percentage of words chosen according to level of pain (P < 0.05).      Patients without pain chose a lower percentage of words than those with mild, moderate, and severe pain, which was expected. Statistically significant differences among patients with mild, moderate, and severe pain were not found.      The words selected to describe venous ulcer pain are presented in Table 3 along with the percentage of patients who selected each word. Sixteen of the 30 descriptors were chosen by more than 30% of patients with VU. Most patients chose sensory words to describe the quality of pain. More than 30% of patients chose the following sensory words: throbbing (n = 28, 70%), pricking (n = 30, 75%), sharp (n = 30, 75%), tender (n = 28, 70%), tugging (n = 26, 65%), burning (n = 26, 65%), sore (n = 26, 65%), and others. In the affective dimension, only 3 words out of 11 were chosen by more than 30% of patients: tiring (n = 20, 50%), sickening (n = 27, 67.5%), and nagging (n = 20, 50%). The word troublesome was chosen by more than 30% of patients in the evaluative domain (Table 2).      No statistically significant difference (P < 0.05) was observed when comparing men and women, patients with and without a partner, diverse religions, educational levels, and age subgroups (35–49, 50–64, and ≥ 65 years), among the 3 SFMPQ dimensions or among the worst, least, and present pain intensities.      The pain management index was computed for all patients with pain. All patients had negative scores (< 0), indicating inadequate analgesia. Although some patients reported moderate or severe worst pain, they were taking only dypirone, acetaminophen, or other nonsteroidal anti-inflammatory drugs (NSAID) as painkillers. No patient was using weak or strong opioids, such as tramadol or morphine.      Quality of life. The highest quality of life score was observed in the social relations domain, followed by psychological domain, and overall QOL. When comparing the 4 WHOQOL-Bref domains among patients with no pain, mild, moderate, and severe pain, it was observed that the only statistically significantly difference was in the overall QOL score. Those without pain showed significantly higher scores—implying better QOL—than patients with mild (P = 0.005), moderate (P = 0.047), and severe pain (P = 0.018, [Table 4]). When examining different areas of QOL, it was observed that patients with severe pain reported lower scores in physical, psychological, and environmental domains compared to those with no, mild, and moderate pain. These differences were not statistically significant (P > 0.05).      Only physical, environmental, and overall QOL domains were significantly correlated (P < 0.05) with intensity of pain (Table 5). Present pain, worst pain, and least pain intensities were significantly, but moderately, correlated with physical QOL (P < 0.001, 0.02, and 0.01, respectively). The least and present pain intensities were moderately (r = -0.32 and r = -0.43, respectively) correlated with environmental QOL domain (P = 0.046; Table 6). Overall QOL was statistically correlated with the intensity of least pain (P = 0.012). On the other hand, no dimension of McGill Pain Questionnaire was significantly correlated with any QOL domains (P > 0.05).      In relation to wound characteristics, only frequency of wounds (the number of times a patient developed a VU) was significantly correlated with any QOL domain. These dimensions were physical and environmental.      The results of the linear multiple regression analyses are shown in Table 7. Intensity of pain was an independent predictor only of overall QOL (β = -0.73; P = 0.03) and social relationship QOL domain (β = -3.85; P < 0.001). Pain impact was higher on the social relationship domain than on the overall QOL (Table 7).      Monthly family income, number of wounds, and intensity of present pain were independent predictors of the overall QOL adjusted by evaluative pain dimension and partnership status. These variables had a strong impact on this domain, explaining 64% (F = 6.93; P < 0.001) of the variance in overall QOL. The physical, psychological, and environmental domains were independently predicted only by frequency of wounds, adjusted by intensity of pain, age, and intensity of present pain, respectively. These models explained similar variance of these 3 domains: 37%, 20%, and 43%, respectively.      Social relationship QOL domain was predicted by intensity of present pain, and its effect was adjusted by sensory pain dimension. An increase of one point in the pain intensity-numerical rating scale resulted in 3.85 decrease in the social relation QOL domain. This model explained 31% of the domain variance.

Discussion

     The effect of pain on overall QOL of patients with VU varied by presence of pain such that overall QOL scores were lower in patients with mild, moderate, or severe pain than in patients without pain. It was also observed that the increase in pain intensity was correlated with reduction in overall QOL and in physical and environmental QOL domains, suggesting a negative impact of pain on these domains. The negative impact of pain on QOL was also suggested by multiple linear regressions, when it was verified that the intensity of present pain was an independent predictor of the overall QOL score and social relationship domain score; multiple linear regressions also adjusted for the effect of frequency of wounds on physical and environmental domains. The impairment of overall physical, social, and environmental QOL in patients with chronic VU was also a result of other factors, such as monthly family income, and the number and frequency of wounds.      Pain was severe in most patients. It was predominantly described using sensory words such as sharp, tender, pricking, throbbing, sore, tugging, and burning, which can characterize neuropathic pain. Nagging, tiring, and annoying were used to describe the effective and evaluative nature of pain. Some of these same words were chosen in other sample of patients with VU. Throbbing, sharp, sore, itchy, and tender were used to describe the sensory pain dimension; tiring and nagging to characterize the affective nature of pain; and as troublesome (being annoying) to describe the evaluative dimension. ²⁶ Another study identified some different words, such as aching, stabbing, sharp, tender, and tiring. ³      Similarly, Gonçalves et al²⁷ also found a predominance of sensory words among patients with leg ulcers, where the most frequent were: throbbing (83.91%), pricking (78.16%), burning (72.41%), and tugging (70.11%), two of which (throbbing and pricking) were common to respondents in the present study. It suggests that the genesis of this pain involved nociceptive and neuropathic mechanisms, characterized by its dysesthetic quality (eg, burning, sharp). ²⁸      In the present study, all of the patients with pain were undermedicated. They took predominantly analgesic nonopioid or NSAIDs by mouth. However, most of them reported severe pain that involved neuropathic mechanisms. Thus, the treatment of pain should also have included not only nonsteroidal anti-inflammatory drugs (NSAIDS) and opioid and nonopioid analgesics, but also adjuvant analgesics, mainly anticonvulsant and antidepressant medications. ²⁸ The topic use of some local anaesthetics, such as Eutectic Mixture of Lidocaine and Prilocaine (EMLA®, AstraZeneca, Wilmington, Del), was associated with pain reduction.29 Some studies have shown that pharmacological interventions are more effective if they are used together with nonpharmacological interventions, such as wound care, ³⁰ patient education about expectations of pain, ³¹ and coping strategies for pain and suffering. ³²      In patients with venous ulcers, pain control may also be increased by using nonpharmacological interventions, such as compression techniques and leg elevation, which reduce edema. ³³ On the other hand, poor technique when applying compression therapy can cause pain. ³⁴ Although all patients with edema in the present study were using compression bandages; perhaps they were not being used appropriately. Thus, it was not an effective pain therapy probably due to insufficient or exacerbated pressure. It highlights that a patient with a VU and healthcare professionals need to be instructed on how to use compression therapy properly, and that patients need to elevate their legs above the level of the heart for 30 minutes, 3 to 4 times a day.      In addition to compression, other factors can cause or exacerbate wound pain, including infection, and trauma at dressing changes. ^34,35 Treatment to reduce infection may reduce pain. ^36,37 In the present study, the presence of wound infection was not assessed. However, since the institutional wound protocol established that in the presence of infection, antibiotics should be prescribed, it could be suggested that infection was not the main source of pain in this sample.      The dressing removal was described as the time of greatest pain. ³⁰ In the present study, patients were interviewed immediately after wound cleansing, which could influence the intensity of pain reported. One way to reduce the potential for pain at dressing change is by using an analgesic a few minutes after dressing to reduce adhesive mass on the dressing, or reduce frequency of changes by using a dressing that has higher absorbency and a longer wear time. ³⁵ Selecting the appropriate dressing is one strategy nurses apply to help prevent pain and trauma at the time of dressing change. ^38,39 Currently, some dressings that release NSAIDs, such as ibuprofen (Biatain® Ibu, Coloplast, Minneapolis, Minn), showed some evidence that they reduce pain and improve QOL. ⁴⁰ In addition to these interventions, it might be helpful to remove the dressing after bathing and showering.      In relation to QOL, the QOL scores for all domains, except social relations, were lower than the mean value of the Brazilian population, ¹⁷ which suggests that the presence of pain associated with VU has a negative impact on QOL. The social relationship QOL of the individuals with chronic VU was slightly higher than that of an average member of the Brazilian population. In univariate analyses, when analyzing the effects of pain on quality of life domains, it was observed that pain affected overall QOL, and physical and environmental domains. However, in a multiple analysis, pain was the only independent predictor of overall QOL, and the social relationship QOL domain scores.      The negative impact of pain on social relations, independence, and overall QOL has been already described, ⁴¹ as well as the negative impact of chronic wounds on physical activities, social functioning, ⁴² functional capacity, overall health condition; physical, pain, and social and emotional aspects; ⁴³ and role-emotional, social functioning, role-functioning, role-physical, and body pain. ⁴⁴      Perhaps, among patients with VU, the presence of pain and not only the wound itself determines the negative impact on QOL, since pain domain was one of those more impaired in the other studies, ^41–44 as well as in the present study, since 90% of patients reported pain. Based on such results and on the multiple regression models presented in the current study, one could argue that adequate pain relief, as well as adequate venous ulcers treatment, could significantly improve overall QOL.      Nemeth et al¹² studied patients with VU and observed that those with pain had a poorer emotional QOL than those without pain; this was not observed in the present study. Patients with pain showed statistically significant lower scores only on overall QOL. Perhaps, wound duration explains this. In the Nemeth et al³ study, patients had been receiving care for less than 13 weeks. In the present study, patients had VU for a median time of 36 months. As time goes by, the perception the patient has regarding QOL can change. This phenomenon has been called “response shift,” which means that an individual can adapt or shift his internal standards, values, and concepts on their QOL in response to some chronic health condition. These “response shifts” can impact or distort results of some QOL measures. ⁴⁵      It was impressive that the frequency of wounds was moderate and positively correlated with physical and environmental QOL. In addition, it was an independent positive and strong predictor of physical, psychological, and environmental domains. Wound characteristics have been identified as having a negative impact on QOL. ⁴⁶ Perhaps, the “response shift” phenomenon could explain such unexpected results.      Although those with severe pain reported lower physical, psychological, and environmental domains than those with none, mild, and moderate pain, this difference was not statistically significant. It could be justified by the small sample size in all groups. Thus, it could be a true absence of association, but could also be a chance result.      As noted, despite all the significant results arising from this study, it showed some limitations. First, it is a cross-sectional study, which does not include a time frame for the expositions and may turn fragile or vulnerable the casualty attributed to pain versus QOL. A prospective study addressing this limitation needs to be performed in the future. Second, the sample size was relatively small if we consider the large number of patients with venous ulcers in Brazil and in the world. Thus, we cannot guarantee its external validity. In addition, it did not assess the presence of lymphedema, pruritus or any other complicating conditions that may affect pain and suffering. Also, it was not evaluated if patients had undergone chronic venous insufficiency surgical procedures. The results should be confirmed in a larger sample.      Despite its limitations, this study will certainly help clinicians and researchers better understand not only the significance of pain among patients with legs ulcers, more specifically chronic venous ulcers, but also its impact on specific QOL domains and overall QOL to these respondents and its use as a basis for treating pain.

Conclusion

     Pain is associated with poor overall physical, social, and environmental QOL, emphasizing the importance of identifying and treating pain. However, overall QOL and physical and environmental domains were also impaired by wound characteristics, such as frequency and number, raising the possibility that optimizing wound treatment may improve QOL.

Acknowledgement

     The authors gratefully thank the nurses from the University Hospital, University of São Paulo, Brazil who helped to enroll patients in this study. From the School of Nursing, University of São Paulo, Brazil