Clinical REVIEW Wound-related pain: anxiety, stress 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 anticipation, the higher their levels of pain during dressing changes. Anxiety as a psychological stress 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 quality of life. 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 chronic wound 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 cholecystokinin has been Canada spontaneous pain. To avoid pain, many documented by Benedetti et al (2006), 92 Wounds UK, 2010, Vol 6, No 4 Woo.indd 2 03/11/2010 09:22 Clinical REVIEW linking stress/anxiety to pain perception. and anxiety). To increase healthcare perception? How does pain affect 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, amygdala 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 suffering from at dressing change. infection 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 signs and symptoms 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 disease. 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 diabetes 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 risk for pressure the epidermis 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 meaning of pain (e.g. a means subjects registered higher levels of Wound-related pain to attract attention, 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 94 Wounds UK, 2010, Vol 6, No 4 Woo.indd 4 03/11/2010 09:23 Clinical