Addressing the Pain: New Approaches to a Timeless Dilemma

We all must die. But if I can save him from days of torture, that is what I feel is my great and ever privilege. Pain is a more terrible lord of mankind than even death itself. - Albert Schweitzer (1875-1965)

  Pain is a highly individualized experience. Because physicians must depend on their patients' subjective and, therefore, varied responses to the sensation, pain is one of the more difficult symptoms, if not to observe and document, then to quantify. In short, pain is challenging to assess and treat.

  Clinical approach to pain, however, is changing. In its 2001 mandate, "Taking the Ouch Out of Pain,"¹ the Joint Commission of Accreditation of Health Care Organizations (JCAHO) set forth standards for long-term care requiring that pain not be ignored. According to JCAHO, long-term care residents have certain pain-related rights, including but not limited to appropriate pain assessment and documentation, referral for management, and education on management beyond the caregiving facility.

  Pain has become a major factor when considering quality-of-life issues. In some healthcare circles, clinicians accept the reality of wound treatment as opposed to wound healing - that similar to certain conditions and diseases (diabetes, for example), complete healing is not yet possible.² Wound care providers, front-line champions of restoring quality of life in the face of chronic situations, have turned their attention to pain and its impact during treatment. They know that pain must be addressed in wound care.

  To this end, Ostomy/Wound Management, with the support of Mölnlycke Health Care, has created the column "Addressing the Pain" to focus on the pain experience as it relates to wound care. Each month, various clinicians renowned for their progressive wound care ideas and practices will lend their expertise to present theory and practical advice on relieving and removing the pain of wound care. Among the potential topics: pain assessment (eg, methods, tools); pain as it relates to different types of wounds, different types of treatment, and age; traditional pain management (eg, dressings and topical and systemic analgesics); alternative and emerging treatments; and patient education and care beyond the healthcare facility. O/WM and Mölnlycke hope to become a resource for wound pain information, linking readers to a network of vital, ever-evolving pain information.

  One critical piece of information comes from the European Wound Management Association (EWMA). In response to increasing acknowledgment that pain is a factor in many different types of wounds, EWMA developed a position document to provide direction for assessing and managing wound pain. This document is specific to dressing changes in chronic wounds.

  In the course of creating the document, EWMA confirmed the paucity of evidence-based practice and literature available. This was underscored by the diversity in approach to care as determined by a multinational survey of wound care professionals. Such diversity may be due to the variations among healthcare delivery systems, along with inconsistent access to and knowledge of products. Indeed, even the JCAHO document notes that the response to patient pain is based on the services the healthcare facility provides.
  A lack of research and protocol did not prevent EWMA from making its case. Its position document presents results of an international collaboration that assessed practitioner views on pain and trauma. Despite perception that studies on the subject are based on soft data, participants validated belief that pain and trauma are vital considerations, especially during dressing changes.³ Findings include which types of dressings and products are the most likely (dried out dressings and products that adhere, such as gauze) and least likely (hydrogels, hydrofibers, alginates, and soft silicones) to cause pain and trauma. The survey results also demonstrate that practitioners place low value on pain assessment tools, preferring to rely on body language and non-verbal communication to ascertain extent of pain.

  The position document includes an article by Wulf and Baron⁴ on the theory of pain. Clinicians' understanding of this theory helps ensure that they comprehend the mechanisms of acute and chronic pain to better grasp their patients' pain experience. Altered pain transmission pathways, tissue damage and inflammation, heightened sensitivity to a repeated stimulus, and peripheral nerve injury are integral parts of perception of and response to pain in the wound and the surrounding periwound area.

  Human compassion (as well as JCAHO) dictates that once pain is identified, it should be addressed. Briggs and Torra i Bou⁵ demonstrate the multidimensional nature of wound pain and its affect on care management. They stress the importance of a broad holistic approach and utilizing a combination of techniques is emphasized.

  The EWMA position document confirms that pain is an important aspect of wound care and that future research is needed to define the type and nature of wound care pain. It also alerts us that clinicians should consider alternative outcomes in wound healing. Wientjes ⁶ explores pain in terms of the mind-body connection in wound healing. She cites Myss,⁷ who says that one of the myths associated with recalcitrant wound healing stems from the concept that feeling pain means being destroyed by pain. As part of treatment, it is important to recognize that pain should be reoriented to become an indication of disease rather than a punishment. Many wound care clinicians agree, referring to pain as "the fifth indicator" or vital sign.

  Confronting the problem of wound pain offers a glimmer of hope for frustrated clinicians and patients, especially those who deal with the pain associated with dressing changes. Research and its subsequent knowledge cannot come soon enough. Ask anyone who has faced the trepidation of simply having a cut and removing an adherent bandage. Wounds hurt. Most dressings cannot be quickly ripped off to avoid prolonging the painful sensation. Acknowledging that pain has a physiological basis helps dispel the skepticism in clinicians' ability to treat what cannot be observed and provides a basis for creating effective therapies. To keep readers abreast of developments in the area of wound pain, future columns will elaborate on the EWMA document and other research findings. Meanwhile, O/WM encourages to clinicians to take what they already know about the benefits of particular dressings and wound care strategies to help their patients through assessment, treatment, and prevention as pain-free as possible. 

1. Joint Commission of Accreditation of Health Care Organization. Joint Commission focuses on pain management. 2001. Available at: www.jcaho.org. Accessed December 5, 2002.

2. Alvarez OM, Meehan M, Ennis W, et al. Chronic wounds: palliative management for the frail population. WOUNDS. 2002;14(8 suppl):5S-27S.

3. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma. In: European Wound Management Society. Position Document: Pain at Wound Dressing Changes. London, UK: Medical Education Partnership Ltd; 2002.

4. Wulf H, Baron R. The theory of pain. In: European Wound Management Society. Position Document: Pain at Wound Dressing Changes. London, UK: Medical Education Partnership Ltd; 2002.

5. Briggs M, Torra i Bou JE. Pain at wound dressing changes: a guide to management. In: European Wound Management Society. Position Document: Pain at Wound Dressing Changes. London, UK: Medical Education Partnership Ltd; 2002.

6. Wientjes KA. Mind-body techniques in wound healing. Ostomy/Wound Management. 2002;48(11):62-67.

7. Myss C. Why People Don't Heal and How They Can. New York, NY: Three Rivers Press;1997. Addressing the Pain is made possible through the support of Mölynlycke Health Care, Newtown, Pa.