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Clinical REVIEW Wound-related : , and wound healing

Pain is a common problem in patients with chronic wounds. This article discusses a systematised approach to address and manage wound-related pain. The impact of psychological factors on pain is often overlooked. Substantial evidence indicates that the more anxiety patients experience from , the higher their levels of pain during dressing changes. Anxiety as a can trigger a cascade of physiological events that impair wound healing. Strategies to allay anxiety must be part of a comprehensive pain treatment plan.

Kevin Y Woo

Studies of patients with venous leg patients are forced to limit their activities KEY WORDS ulcers indicated that as many as 80% which affects their personal life (e.g. of patients reported acute or chronic bathing, shopping), social, family, and Wound-related pain wound pain, with half of them rating work life, thereby eroding their overall Anxiety and stress pain as moderate to the worst possible . Patients describe wound- Quality of life pain (Briggs and Nelson, 2010). Patients related pain as all-encompassing and Dressing changes one of the most devastating aspects of living with chronic wounds (Price et al, Increased levels of stress 2008). However, the management of and heightened anxiety pain by healthcare professionals is often have been demonstrated relegated to a lower priority (Vermeulen ain is common in patients living to lower pain threshold and et al, 2007). with chronic wounds (Woo and tolerance, as the person may PSibbald, 2008). Wound-related Stress and anxiety pain may be exacerbated at the time become more vigilant of Collectively, emerging evidence of dressing change, but it may also be somatic signals. The result is indicates that pain constitutes a major persistent between dressing changes a vicious cycle of pain, stress/ source of stress in patients with (Woo et al, 2008). Recognising the anxiety, and worsening chronic wounds (Hyde et al, 1999; primacy of pain as part of of pain. Beitz and Goldberg, 2005; Hareendran management, international consensus et al, 2005). Increased levels of stress documents place the emphasis on the and heightened anxiety have been need to assume all chronic wounds demonstrated to lower pain threshold are painful unless the patient indicates gave vivid descriptions of the pain and tolerance, as the person may otherwise (Woo et al, 2008). experiences even after the leg ulcers become more vigilant of somatic signals. had healed. Of the 132 patients who The result is a vicious cycle of pain, developed pressure ulcers, Dallam et al stress/anxiety, and worsening of pain. (1995) reported that 59% experienced some type of pain in a hospital setting. To encapsulate this unique Szor and Bourguignon (1999) explored phenomenon in which pain is intensified pain in 32 patients with pressure ulcers. by stress/anxiety, Colloca and Benedetti Most of the participants (75%) rated (2007) eloquently explained the pain as distressing, while 18% described ‘nocebo effect’ (versus placebo effect). pain as horrible or excruciating. Individuals who express high levels of Kevin Y Woo is Director of Nursing/Wound Care Specialist, Villa Colombo, Homes for the Aged, Inc, Toronto, Ontario, Consistent with previous findings, stress or anxiety in anticipation of pain, Canada; Wound Care Consultant, West Park Healthcare Meaume et al (2004) reported that also rate the actual pain experience as Centre, Toronto, Canada; and Assistant Professor, Lawrence 77% of a large sample of 2936 patients more intense. A possible neural circuitry S. Bloomberg Faculty of Nursing, University of Toronto, with chronic wounds experienced mediated by has been Canada spontaneous pain. To avoid pain, many documented by Benedetti et al (2006),

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linking stress/anxiety to pain perception. and anxiety). To increase healthcare perception? How does pain Other neurobiological studies have professionals’ awareness of the patient quality of life? Various identified potential involvement of complexity of wound-related pain, the contextual factors, beliefs, attitudes, cortical and subcortical circuitries, wound-related pain model developed past experience and expectations including the periaqueductal gray by Woo and Sibbald (2008) (Figure 1) can influence pain perception. As matter (PAG), frontal cingulate and proposes a systematic approach to illustrated by the findings reported insular cortices, limbic system, ensure that the cause of the wound, by Woo et al (2009), pain and and hypothalamus (Rainville et al, 1997; local wound care issues and patient- anxiety are interconnected and Price, 2002; Bush et al, 2000: Apkarian centred concerns are adequately circular in patients with chronic et al, 2005). assessed and treated (Woo and Sibbald, wounds. Anxious patients have a propensity to anticipate more painful Anxiety has been correlated with Anxious patients have a symptoms. The anticipated effect increased wound-related pain both propensity to anticipate of pain has been demonstrated to at dressing change and between intensify the actual pain experience dressing changes. Aaron et al (2001) more painful symptoms. at dressing change demonstrated that anxiety is a significant The anticipated effect 8 Local wound factors: is there predictor of procedural pain during of pain has been recurring trauma (at dressing dressing change and accounts for 40% demonstrated to intensify changes or other times) to the of the variance of reported burn- the actual pain experience wound? Is there an undiagnosed related pain. In patients from at dressing change. or inflammatory pathology? pain related to chronic venous ulcers Is there too much or too little (Jones et al, 2006), 27% of the subjects moisture? Tissue trauma, infection were considered depressed, while 26% 2008). The primary goal is to improve (increased bacterial burden) and were considered anxious. It was also patient outcomes and enhance patient poor moisture balance (either too demonstrated that the higher their levels quality of life, even when healing is not dry or too wet in the wound milieu) of pain, the more anxiety experienced. expected (i.e. with non-healable wounds may contribute to pain. Gardner et (p<0.001). because the cause cannot be corrected, al (2001) evaluated the validity of or maintenance wounds when patient 12 clinical to In a more recent study, Woo adherence to the treatment plan identify localised infection among (2010) asked 96 patients with chronic is poor). 36 individuals with chronic wounds. wounds to indicate their anticipatory None of the subjects in this study pain before dressing changes and to The key components of the wound- with non-infected wounds exhibited rate the intensity of pain at various related pain model are: increasing pain as an indicator. The intervals during dressing changes using 8 Cause(s) of the wound: is pain reported specificity of 1.0 in the a visual analogue scale (VAS). Anxiety related to the underlying pathology study indicated that pain is a key was also evaluated with a shortened of the wound? Leg ulcers may parameter for wound assessment. state anxiety instrument that consisted be painful due to the associated of six word descriptors including oedema of venous . Dressing removal is painful worried, calm, tense, upset, nervous, Other differential diagnoses when the contact layer adheres and anxious from the Spielberger state- related to pain may include acute to the wound bed due to dried trait anxiety inventory (Spielberger lipodermatosclerosis, infection, out materials, aggressive adhesives, et al, 1970). Pearson’s correlation along with superficial or deep granulation tissue and capillary loops coefficients were calculated to examine phlebitis. A person with growing into the product matrix, or the relationships among variables. may experience pain as a result of the glue-like nature of dehydrated Anxiety was positively and significantly neuropathy, infection of the deep (crusted) exudate. Enzyme-rich correlated to anticipatory pain (.67), tissue including osteomyelitis, or exudate may spill over to wound pain at dressing removal (.53) and pain a deep disruption of the bony margins causing maceration or during wound cleansing (.46). Patients structure due to Charcot changes. tissue erosion (loss of part of who experienced higher levels of anxiety Among patients at for pressure the but maintaining an anticipated more pain and experienced ulcers, ischaemic or deep tissue epidermal base), with an increased more intense pain during dressing injury (tissue deformation) can also risk of trauma (Woo et al, 2008). In changes than patients with lower levels be painful (Woo and Sibbald, 2008) a randomised control trial (RCT) of anxiety. 8 Patient-centred concerns: what is comparing two foam dressings, the of pain (e.g. a means subjects registered higher levels of Wound-related pain to attract , challenge to background pain with macerated Wound-related pain involves an intricate overcome, punishment, personal periwound areas (Blackburn-Munro, interplay of various underestimated defeat)? What are the psychosocial 2004). In a recent study, Woo systemic and patient factors (i.e. stress factors that may impact on pain (2010) indicated that cleansing

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that involves scrubbing and cold inflammatory response, suppresses examined the key determinants for solutions can evoke a significant cellular differentiation and proliferation, the healing of venous and mixed amount of pain. inhibits the regeneration of endothelial venous/arterial ulcers (n=155). Using cells and delays collagen synthesis. In a hierarchical multiple regression Relationship between pain the presence of , T-cells become analysis, pain on mobility was found to and wound healing less responsive to the interleukin-1 be a significant predictor for wound Pain and stress may slow wound healing (IL-1) signalling for the production healing (B=.46, p<.0001). Kiecolt- through various intricate mechanisms. of growth factors that facilitate T-cell Glaser et al (1995) compared wound Chronic wound-related pain constitutes proliferation (Johnson, 1995). healing in 13 women caregivers (mean a psychological that triggers age=62.3 years) who had a relative with the hypothalamic-pituitary-adrenal To validate the relationship between Alzheimer’s disease and 13 controls axis promoting the production of and wound healing, matched for age (mean age=60.4 vasopressin and McGuire et al (2006) studied 17 women years). All the subjects acquired a (cortisol) (McGuire et al, 2006). who underwent gastric bypass surgery. wound from a 3.5mm punch biopsy Vassopressin is a potent vasoconstrictor Patient pain ratings over four weeks post at the same anatomical location (non- compromising the delivery of oxygen surgery were significantly associated dominant forearms). Time to achieve and nutrients for wound healing. with delayed healing of a 2.0mm punch complete wound closure was increased Cortisol reduces the immuno- biopsy wound site. Glaser et al (1999) by 24% or nine days longer in the stressed caregiver versus control groups (p<0.05). Caregivers’ peripheral blood leukocytes exhibited a diminished ability Venous ulcer Ischaemic ulcer Pressure ulcer Diabetic foot Other causes to express the IL-1ß gene in response pain pain pain ulcer pain of pain to lipopolysaccharide in vitro. Interleukins play an important role to Oedema Ischaemia Deep tissue injury Sensory Infection protect the host against infection and Lipodermato- Claudication Pressure neuropathy Inflammation prepare injured tissue for repair by sclerosis Vasospasm Shear Deep tissue (vasculitis, enhancing phagocytic cell recruitment Phlebitis Reperfusion injury Friction destruction pyoderma and activation (Glaser and Kiecolt- Atrophie blanche Immobility (Charcot changes) gangrenosum) Glaser, 2005). Incontinence Autonomic Malignancy dysfunction Based on previous findings, Glaser et al (1999) examined psychological stress and the levels of proinflammatory cytokines in experimentally-induced skin Tissue debridement Infection/inflammation: Moisture balance: blisters on the forearms of 36 women and trauma: Increased bioburden/ Too little Too much (mean ±SD age, 57.2 ±6.6 years). The Selection of dressings and infection Adherent Heavy exudation specimens were aspirated and analysed frequency of change Increased inflammatory dressing Periwound within 24 hours of blister formation. Aggressive adhesives mediators Bleeding maceration Women who reported more stress on Wound cleansing/irrigation Topical application of Trauma the Perceived Stress Scale produced Tissue debridement irritants/allergens Malodour significantly lower levels of IL-1 (p<0.03) and IL-8 (p<0.04).

In another study, Garg et al (2001) Wound-associated pain observed the skin barrier recovery rate Topical: lidocaine, , NSAIDs from damage caused by tape stripping in Systemic agents: nociceptive vs. neuropathic 27 university students. Serial assessments WHO analgesic ladder were performed on three occasions: after the winter holiday when stress levels were low, during examination week with high stress levels, and after Patient-centred concerns the spring holiday when stress levels Past pain experience Psychological: , anxiety, stress waned. Consistent with their hypothesis, Patients’ expectation and treatment goals the investigators reported that barrier Awareness of disease/pain/treatment recovery was significantly slower during Active patient involvement (coherence) the high stress periods compared to the low stress periods (F=18.87; df=12.2; Figure 1. Wound-related pain model: the wound, the cause, the patient (Woo and Sibbald, 2008). p<0.001). The correlation coefficient

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for the relationship between stress and tapestry of pain assessment (Woo et al, barrier recovery was significant (r=- 2008). While no one is immune to the 0.42; p=0.03), indicating the higher the of anxiety before a potentially stress, the slower the barrier recovery painful procedure, strategies that allay Key points rate. Similar findings were reported by anxiety may lessen the pain experience. Ebrecht et al (2004), who monitored Clinicians should pay attention to 8 Pain is a common problem wound healing in dermal biopsy sites other sources of anxiety that may be in patients with chronic among 24 subjects, found that stress associated with stalled wound healing, wounds. and emotional distress were negatively such as of amputation, body correlated to wound healing rate disfigurement, repulsive odour, social 8 Wound-related pain is linked between day seven and 21 after the , debility and disruption of daily to anxiety, constituting a biopsy (p<0.05). activities (Price et al, 2008; Woo et al, significant psychological 2008; Woo, 2010). stressor. Although causality between pain and 8 healing cannot be inferred, venous leg While no one is immune Stress promotes the production of hormones and ulcer patients who were randomised to the feelings of anxiety to a nurse-managed leg club achieved vassopressin that can impair a 76.8% reduction in mean ulcer size before a potentially painful wound healing. (mean 10.3cm2 to 2.39cm2), with a procedure, strategies that significant reduction in pain levels over allay anxiety may lessen the 8 Anxiety must be addressed 12 weeks (p=0.001) (Edwards et al, pain experience. to reduce wound-related 2005). In contrast, mean ulcer size was pain. merely reduced by 11.8% in the control group (7.63cm2 to 6.8cm2) without any A therapeutic relationship between significant changes in pain scores. Leg the healthcare professional and clubs create a social platform for patients the patient can enhance treatment to support, empathise and empower adherence to optimise patient outcomes each other, bolstering their abilities to (Robinson et al, 2008). Crucial to 8 Enlist patient participation by cope with pain and associated stress. cultivating a therapeutic alliance, clinicians actively engaging them during the must first acknowledge that anxiety procedure and giving them In a prospective study, Woo and and pain are common experiences at permission to call time-outs. Sibbald (2009) followed 102 patients dressing changes. While patients should with either leg or foot ulcers for four be informed that these symptoms are Conclusion weeks. Pain was measured with a part of a normal response, emphasis Pain is a common symptom for numerical rating scale (with 0 the should be placed on available treatment persons with chronic wounds. The least pain and 10 the most severe pain). options and achievable goals to minimise pain experience continues to generate Almost half of the subjects (45.6%) were them. Based on Keller and Carrolls’ conceptual and methodological debate inflicted with severe pain (pain ratings suggestions (1994), the following due to its vicissitude. Troublesome of 7 or above) in relation to their ulcers. communication strategies are proposed: pain symptoms may evolve from one The average level of pain was reduced 8 Engage patients by talking about their or more sources, including wound from 6.3 at week 0 to 2.8 at week 4 pain and their concern about wound aetiologies and local wound care such (p<0.001). To examine the relationship care and dressing changes. There as surgical debridement procedures between pain and wound healing, pain is a need to reinforce the belief or dressing changes. Sub-optimal local levels were compared in two groups that patients with chronic wounds components of the wound base that of patients by separating those who do not have to live with persistent may be associated with pain include achieved wound closure and those who or temporary pain, and active unwanted debris, bacterial damage did not. The mean pain score was 1.67 participation in their assessment, from superficial critical colonisation or for the patients who had their wounds treatment and behaviours deep compartment infection, abnormal healed, in contrast to 3.21 for those who should be fostered inflammation, or moisture imbalance did not achieve complete wound closure 8 Empathise the impact of pain for (excess or paucity). (p<0.041). individuals with chronic wounds 8 Educate patients by explaining It is crucial to remember that Therapeutic relationship and procedures and how they are chronic wound-related pain is pain management performed. Pain-related education is linked not only to abnormal wound Effective management of pain not only a necessary step as it helps to dispel characteristics, such as infection, requires the use of pharmacological common misconceptions and myths trauma and ischaemic injury, but also to agents, but also mindful attention to that may obstruct effective suffering (Krasner, 1998). Pain psychological factors that are part of the pain management has a great impact on quality of life,

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