Pain in Acute and Chronic Wounds: A Descriptive Study

    Pain is possibly the most feared sensation in life. In the authors’ opinion, pain disables and distresses more people than any single disease entity and may be the most compelling reason a person seeks healthcare.

The significance of pain is neglected in wound care. Internationally, clinicians may ignore patient pain because it is not easy to measure, exhibit biases against pain management, or lack knowledge of available analgesics. Pain is a component of quality of life.¹ Patient-centered concerns need to address pain control measures until the cause of the pain can be corrected.

    This 1-day descriptive study was conducted to assess various parameters related to pain in patients with acute and chronic wounds.

Literature Review

    Wound pain has been the subject of various studies. Understanding the mechanisms of pain and how they relate to chronic wounds enables wound care specialists to improve their patients’ quality of life.
In a study describing patients’ experiences living with a leg ulcer, pain was found to be the most overwhelming characteristic of the condition and was exacerbated by simple activities of daily living such as walking or standing.² The study also found that most patients were concerned with the issue of healing; this is in contrast to another study³ in which it was reported that only 3.4% of patients mentioned they were worried about healing.

    Pain should be quantified. Assigning and documenting a measurement of pain gives patients some sense of control over their condition and has a positive effect on their ability to cope.³ Pain measurements also provide a means of assessing the efficacy of response to treatment and prognosis. The Visual Analog Scale (VAS) is a well-studied, validated tool used to measure acute and chronic pain that enables patients to indicate the extent of pain via points on a line from “no pain” to “worst pain I can imagine.”³ The Verbal Reporting Scale (VRS) utilizes adjectives to describe pain intensity. The VRS has been found to be a simpler, more time-conserving instrument as compared to the VAS.⁴

    A complex and highly subjective construct, pain comprises multiple dimensions and is modulated by the context and meaning in which it emerges.⁵ Pain management must incorporate the impact of body disfigurement, family burden, guilt, and patient shame. Krasner⁶ conducted a phenomenological study of 42 nurses who cared for patients with wounds and found that nurses who cared for patients in pain often coped by denying or ignoring the patients’ pain. Krasner reported that healthcare providers are better able to confront the challenge of a patient’s pain when they come to terms with their own feelings of frustration, anger, helplessness, and hopelessness.⁶

Patients and Methods

    This 1-day, descriptive study was conducted by surgical residents in the wound clinic of a university hospital in Varanasi, India. It involved 50 consecutive patients suffering from acute (duration <6 weeks)and chronic wounds (duration >6 weeks) who visited the once-a-week clinic on a particular day. The study was explained to patients and informed consent was obtained. Patients responded to questions related to wound pain such as the onset, location, type, and intensity using visual analogue and verbal reporting scales. Responses to statements regarding aggravating and relieving factors and overall impact of pain on quality of life were obtained using a 5-point scale where 5 = totally agree and 1 = completely disagree.

    Tools. The VAS consists of a 100-mm, horizontal illustration (see Figure 1) on which the patient is asked to mark the point on the line between “no pain” and “worst pain I can imagine” that best describes the symptom. The VRS is a five-point scale with declarative statements at each of the points. Patients are asked to choose the number that best describes their current opinion about pain. Points on this ordinal scale are not equidistant but are ranked in a hierarchical order to suggest that “mild” is worse than “no pain” but better than “moderate,” and so on. Patients also were asked about various quality-of-life parameters (see Table 1) — scores of 1 to 5 were given to various questions, where 5 = totally agree and 1 = completely disagree. The scores were added and mean value was obtained between the highest and the lowest score and then divided into two grades. Scores above mean were ranked “satisfactory” and below the mean “unsatisfactory.”

Results

    The study group comprised 37 (74%) men and 13 (26%) women ranging in age from 7 to 74 years (see Table 2). Trauma was the leading cause of wounds (33, 66%) and the majority of wounds occurred in lower limbs (39, 78%). Of the 50 patients studied, pain was present in 46 (92%). The four (8%) patients who did not experience pain had neurological disorders (see Table 3). All 26 patients with acute wounds and 20 (83.3%) patients with chronic wounds experienced pain; 38 (83%) reported pain was acute in onset and eight (17.4%) said onset was insidious. Pain was present intermittently in 33 patients (71.7%), while 13 (28.3%) said they were in continuous pain. The most common location of pain was in and around the wound (43 patients, 93.5%).

    Of the 50 participants, 31 (63%) rated their pain from 3 to 5 on the VAS (see Figure 2) and 45 (88%) rated their pain “mild” to “moderate” in intensity on the VRS (see Figure 3). In 30 patients (65%), dressing change aggravated pain and in 17 (37%) patients, movement of the afflicted area aggravated existing pain. Non-steroidal anti-inflammatory drugs (NSAIDS) relieved pain in 39 patients (84.8%). Pain most commonly had a negative effect on patient’s physical (40 patients, 86%) and social (23 patients, 50%) aspects of life.

Discussion

    Pain can be defined as an unpleasant sensory and emotional (conscious) experience associated with actual or potential tissue damage. Pain acts as a natural alarm for injury or tissue compromise. Without this indicator, repeated trauma is apt to lead to further tissue destruction. Chronic pain is distressing and influences the person’s ability to function.⁶

    Of the 50 patients with chronic and acute wounds, 46 (92%) experienced pain; four (8%) had no pain secondary to neurological disorders. In a study of pain and pressure ulcers, Lindholm et al⁷ reported that pain was present in almost 50% of patients with leg and foot ulcers. In a study by Dallam et al,⁸ 59% of patients reported pain of some type; this increased to 68% when the faces scale was the method of assessment.

    Using visual and verbal analogue scales to assess the intensity of pain in the current study, 63% of the patients rated their pain from 3 to 5 on the VAS and 88% rated their pain “mild” to “moderate” in intensity on the VRS. Almost all patients (93%) experienced pain both in and around the wound; three (6.5%) had pain in other areas related to their wounds. In a 94-patient study, Hofman⁹ found that the main areas of pain were within and around the ulcer; in that same study, 64% of the patients rated their pain “severe” and 50% used mild or no analgesia.

    Wound pain has a variety of causes. In the current study, the most common aggravating stimulus for pain was dressing change (65%). Movement of the affected part caused pain in 17 (37%) patients. A study conducted by the European Wound Management Association found that 63% of patients experience pain at the time of dressing change.¹⁰ An additional 30% experienced pain during routine wound cleansing. Adherent or dried out dressings are the most likely wound coverings to cause pain and trauma. Another study¹¹ reported that 87% of participants experienced pain at dressing changes.

    Social and emotional factors contribute to the pain experience, affecting quality of life. Emotional responses such as depression, anger, and frustration are related to the degree of acceptance of the situation.¹⁰ In the present study, pain affected physical aspects of life in 87% of patients and social aspects in 50% of participants’ lives. In addition, pain also affected psychological (13%), spiritual (13%), and attitudinal (19.6%) aspects.

Conclusions

    Clinicians need to focus on the patient’s perspective of pain and its root cause. An effective pain control management program is a crucial component of wound assessment and treatment. The most important principle in pain management is to listen to the patient (especially regarding dressing changes and the need for pain medication) and provide care accordingly. A patient-centered regimen ensures appropriate care in a reduced-pain environment.

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