Pain is an unpleasant sensation and results from the brain's response to actual or potential tissue injury (Woolf, 2010). The pain felt after initial tissue injury has a protective role, alerting that the person's body that damage has occurred and signalling that rest is required for tissue regeneration (Hulf and Baron, 2002). It has been suggested that health professionals tend to focus on the assessment of the wound itself, rather than the pain experienced by the patient (Frescos, 2018; Newbern, 2018).
Although most wounds are painful, the pain associated with chronic wounds, which may take 6-8 months to heal, can also lead to sleep disturbance, depression, anxiety, feelings of hopelessness and the inability to undertake basic activities of daily living (Newbern, 2018). It has been estimated that between 48-81% of patients with chronic wounds report experiencing moderate to severe pain (Newbern, 2018). Moffatt et al (2002) argue that successful treatment tends to focus on complete healing of a wound as an outcome; however, for a small number of patients, healing may not be possible, and alternative patient-centred outcomes, such as reduction of pain or improved quality of life, should be considered.
Different wounds produce different types of pain, and may even demonstrate a combination of both neuropathic and nociceptive pain. Table 1 lists the varieties of pain according to wound type.
Table 1. Types of wound pain
| Cause | Description |
|---|---|
| Venous or arterial insufficiency | Patients with venous disease describe their pain as aching heaviness. Pain from arterial disease is described as cramping or spasms when associated with activity |
| Pressure ulcers | Pain may be caused by inflammation and irritation from friction and shearing forces. An increase in pain may indicate infection, inappropriate dressing technique and skin irritation |
| Diabetic neuropathy ulcer | Patients may report shooting, tingling, burning or stabbing sensations. May be spontaneous, continuous or intermittent |
| Atrophe blanche | Skin disorder associated with venous insufficiency, manifested by severe, sharp pain |
Adapted from Maier (2010)
Assessing pain
Pain assessment should form part of the initial wound assessment, and there are many pain tools available. Nemeth et al (2003) reviewed the five most commonly used tools for measuring leg ulcer pain, which included:
- The pain ruler (Bourbonnais, 1981) (Figure 1)
- The numerical rating scale (Downie et al, 1978)
- The visual analogue scale (Huskisson, 1974) (Figure 2)
- The verbal descriptor scale (Keele, 1948)
- The short-form McGill Pain Questionnaire (Melzack, 1987).
Nemeth et al (2003) concluded that, while these were generic and not specific to leg ulcer pain, the health professional must choose the most appropriate tool for their clinical setting, and ease of use and simplicity is key when allowing for current time restraints and staff shortages (Nemeth et al, 2003). It is also important to use the same tool consistently to monitor the effectiveness of pain management strategies.
With the acknowledgement that wound pain affects a patient's quality of life, pain is now finally being incorporated as a dimension into wound quality of life measures, such as the WOUND-Q© (Newbern, 2018; Klassen et al, 2020). However, the assessment of pain should not be limited to the completion of a written assessment tool. Verbal cues solicited through questioning of the patient, relating to the pain's intensity, quality, location, onset, duration and frequency, and aggravating and relieving factors, will provide a pain history (Frescos, 2018). Observing non-verbal cues, such as grimacing, guarding the affected area and limited movement, will also provide a comprehensive picture; however, in some cases, it may be necessary to gather this information and pain history from other sources, such as family or carers (Herr, 2011).
Types of pain
Wound pain can be categorised into the following:
- Background pain: continuous or intermittent pain that is felt even at rest
- Incident pain: pain that occurs during day-to-day activities, such as mobilisation or coughing
- Procedural or operative pain: pain that results from routine procedures, such as dressing, changes or wound cleansing and is associated with wound interventions, such as debridement or biopsies
- Allodynia: pain experienced from something that would not normally cause pain, such as a light touch on the skin
- Hyperalgesia: an increased level of pain from what may appear to be only a minor stimulus (Mudge and Orsted, 2010).
There are broadly two key types of pain: nociceptive and neuropathic. Acute nociceptive pain arises from damaged tissue, where signals are picked up by sensory receptors in the nerve endings of damaged tissue. The nerves transmit the signals to the brain via the spinal cord, where they are interpreted as pain (Mudge and Orsted, 2010). Acute or nociceptive pain is an inflammatory response to painful or noxious stimuli (tissue damage) and is usually time-limited (Hulf and Baron, 2002). Patients experiencing nociceptive pain may use descriptors such as ‘aching’ or ‘throbbing’ to describe their sensation of pain. Table 2 outlines some indicators to help health professionals determine whether the patient is suffering from neuropathic or nociceptive pain.
Table 2. Differentiating pain indicators
| Neuropathic pain | Nociceptive pain |
|---|---|
| Is the patient's skin or wound abnormally sensitive to touch? | Is there an underlying condition, such as ischaemia or tissue damage? |
| Does the patient experience unpleasant sensations even when their skin is touched lightly? | May be as a result of prolonged healing, such as post-burn injury |
| Do they describe their pain as ‘pricking’, ‘tingling’, or as ‘pins and needles’? | Due to the release of inflammatory markers that occur on injury |
| Does the pain manifest suddenly in bursts for no apparent reason? | Patients may use descriptors such as ‘nagging’, ‘throbbing’ or ‘gnawing’ |
| Has the temperature in the painful area changed? Does the patient describe this as ‘hot’ or ‘burning’? | Associated with chronic pain, where there may be a combination of nociceptive and neuropathic pain |
Adapted from White and Harding (2006)
Neuropathic pain occurs by damage to or dysfunction of the nervous system and is often related to pain in chronic wounds. Patients feeling neuropathic pain use expressions such as ‘burning, ‘tingling’ or ‘shooting’ (European Wound Management Association, 2002; Mudge and Orsted, 2010).
Allodynia and hyperalgesia
Experiencing pain for long periods of time can result in physiological changes that alter and increase the patient's perception of pain (Mudge and Orsted, 2010). When the pain pathway is continually stimulated, this can result in increased sensitivity of the peripheral pain receptors, known at primary hyperalgesia, and increased transmission of pain impulses to and within the brain, referred to as secondary hyperalgesia (Mudge and Orsted, 2010). As a result, the patient experiences an increased level of pain from what may appear to be only a minor stimulus. In addition, the patient may experience allodynia, which is the sensation of pain from something that would not normally cause pain, such as a light touch on the skin, or a draught from an open window on the wound. These indicate that the patient is experiencing neuropathic pain (Jensen and Finnerup, 2014).
Pain as a result of wound infection
Patients with wound infection often experience pain. This is because of the inflammatory response to the bacteria in the wound. When there are high levels of bacteria within a wound, white cells release enzymes and free radicals, which cause tissue damage (Cutting et al, 2013). An increase in pain or a change in the nature of pain, unexpected pain or tenderness and/or the onset of pain in a previously pain-free wound are widely accepted clinical indicators of wound infection (Cutting et al, 2013).
Health professionals’ perceptions of painful wounds
Moffatt et al (2002) undertook a survey using a questionnaire that aimed to identify health professionals’ primary considerations in their approach to pain and trauma during dressing changes, and the strategies used to minimise these. Some 11 countries took part in the survey; the response rate was 27%. Participants were invited to rank the wounds that they considered to be the most painful. Leg ulceration was ranked as the most painful, with burns ranked second. Other wounds, such as infected wounds, pressure ulcers, cuts and abrasions, paediatric wounds, cavity and fungating wounds, were considered less painful (Moffatt et al, 2002). The health professionals also ranked dressing change as the most painful procedure, with cleansing ranked as the second most painful intervention. Moffatt et al (2002) commented that this raised issues around which cleansing methods and techniques were being used. It would have been interesting to incorporate the patient perspective and ascertain whether their views may have differed from those of the health professionals.
More recently, Cutting et al (2013) surveyed international wound experts, to investigate if a relationship exists between wound infection, dressings and pain in chronic wounds. The researchers concluded that patients with infected wounds experience more pain than those with non-infected wounds, and that dressing changes in particular caused the highest level of pain, which they called ‘event-related’ pain. The experts were then asked to rank the wound products which, in their opinion, caused the most pain (Table 3). Unfortunately, the patient perspective was not ascertained in this survey.
Table 3. Wound products that experts felt caused the most pain
| Dressing type | Mean | Standard deviation |
|---|---|---|
| Foams | 4.2 | 2.4 |
| Super absorbent dressings | 4.4 | 1.8 |
| Cadexomer Iodine | 4.6 | 2.3 |
| Alginates | 4.7 | 2.2 |
| Silver dressings | 4.8 | 1.6 |
| Fibrous dressings | 5.0 | 2.1 |
| Capillary dressings | 5.1 | 2.0 |
| Honey | 5.7 | 2.1 |
| Semi-permeable films | 5.8 | 2.0 |
| Basic contact layers | 6.0 | 2.7 |
| Negative pressure wound therapy (NPWT) drapes/foams | 6.4 | 2.2 |
| Gauze | 8.2 | 1.0 |
| Adhesives (dressings or tape) | 8.4 | 0.7 |
Adaped from Cutting et al (2013). The higher the mean score, the more painful the dressing was
Minimising pain during dressing changes
According to Briggs and Torra i Bou (2002), pain at dressing change can be minimised by:
- Not allowing dressings, such as dry gauze, film or paraffin gauze dressings, to dry out and stick to the wound bed and surrounding skin (Bethell, 2003). Change dressings according to the manufacturer's instructions
- Ensuring the secondary dressing is appropriate and will maintain a moist environment when using products such as hydrogels, hydrofibres and alginates
- Ensuring the surrounding skin is supported when removing dressings and using skin barrier products to protect the wound margins to avoid excoriation, which can be painful
- Handling the wound carefully and only cleansing if absolutely necessary. Be aware that even gently handling can cause extreme pain (hyperalgesia)
- Using adhesive removal products, such as Appeel© (Clinimed), to assist in the removal of adhesive products. Soaking off dried dressings is no longer recommended, as a moist healing environment is recommended. If soaking is required, it may indicate that the product is not suitable for the exudate levels of the wound or the patient's skin (Moffatt et al, 2002)
- Using dressings with a silicone coating where possible, which are designed for easy removal
- Treating any infection appropriately and ensuring that the increased exudate levels are managed effectively. In wounds with high exudate levels, the peri-wound skin must also be protected
- Considering whether individual patients could remove their own dressings at their own speed
- Reducing any draught from windows or a sudden change in temperature during dressing changes. Avoid poking or prodding the wound, as this will minimise allodynia
- Reassuring the patient that you will stop the procedure when asked to do so. If the pain is severe, allow for ‘time out’ sessions and pause the procedure until the patient gives an indication to continue.
Psychological aspects of pain
Pain is now recognised to be multi-faceted and is influenced by many factors, such as emotions, social background, the meaning of pain to the patient and their beliefs, attitudes and expectations of pain (Fresco, 2018). Some patients may perceive pain as an inevitable consequence of their condition that must be tolerated (Mudge, 2007; Hellström et al, 2016). Many patients, particularly older patients, do not report pain, for fear of being seen as difficult or annoying (Bengtsson et al, 2008). Gorecki et al (2011) found that pain may also be under-recognised, particularly in those with cognitive impairment or communication difficulties; furthermore, they also found that patients describe not having their pain acknowledged or managed appropriately.
Prior experience of pain will also affect patients. For example, if a patient has experienced pain during a dressing change, they will become anxious and tense and anticipate pain every time the dressing is changed.
Wound pain management strategies
Pharmacological
Pain assessment should be performed regularly and not as a one-off initial assessment. The use of a pain tool is helpful, particularly to gauge the effectiveness of any analgesia. However, health professionals should not rely solely on a pain tool, but must also observe the patient. Non-verbal cues, such as grimacing, guarding the area and restricted movement, should also be noted (Brown, 2014).
If analgesia is being used to treat wound pain, its effectiveness should be monitored on an ongoing basis. Several types of analgesia can be used to manage wound pain, and the type prescribed should be based on the type of wound pain and level of pain experienced by the patient. Determining whether the pain is neuropathic or nociceptive, or a combination of both, will enable the health professional to prescribe the most appropriate analgesia.
Patients must be advised to take analgesia as prescribed, and not wait until the pain starts. This is particularly important for older people who may have a fear of polypharmacy and dependency or addiction to opioid medication (Vuolo, 2009; Herr, 2011).
The most commonly used regime for managing pain is the World Health Organization's (WHO) Analgesia Ladder (1996), which was adapted for wound pain by Senecal (1999). Box 1 outlines Senecal's adaptation of the WHO ladder.
For neuropathic pain, adding amitriptyline, gabapentin or pregabalin can be effective (NHS Lanarkshire, 2022).
Box 1.Senecal's (1999) adaptation of the World Health Organization's (1996) pain ladderSTEP 1
- Use non-steroidal anti-inflammatory drugs, such as aspirin or ibuprofen, in combination with a local anaesthetic, such as Emla cream if appropriate
STEP 2
- Add a mild opioid, such as codeine (use oral medication if possible) STEP 3
- Replace the mild opioid with a potent opioid, such as buprenorphine or morphine
Non-pharmaceutical management strategies
Non-pharmaceutical strategies, such as aromatherapy, reflexology and reiki, and distraction therapies, such as television, music, guided imagery or just chatting to the patient, can be useful if used alongside pharmacological pain management. These are particularly valuable if patients are reluctant to take analgesia, or if the analgesia is poorly tolerated.
Improved sleep patterns, mobility and feelings of wellbeing have been noted with aromatherapy (Howarth, 2002; Walsh and Radcliffe, 2002). Williams and Irurita (2004) found that distraction therapy helped patients focus on a pleasant stimulus instead of painful or stressful situations, and resulted in emotional comfort and a reduction in pain.
Indovina et al (2018) evaluated virtual reality as a distraction intervention to alleviate pain and distress during medical procedures and found it to be effective in reducing procedural pain in patients with burn injuries undergoing wound care and physical therapy.
Mackey (2001) and Stephenson et al (2003) found that reflexology gave patients a greater sense of wellbeing and being cared for as a result of being touched. They concluded that, psychologically, being touched is therapeutic for patients with both acute and chronic wounds.
Both Alandydy and Alandydy (1999) and Wardell and Engebretson (2001) found that reiki, where the lifeforce energy is directed to the area of injury, resulted in reduced analgesia use, increased wellbeing and decreased emotional distress.
Gottrup et al (2007) conducted a randomised, controlled, double-blind clinical investigation to determine the efficacy of a soft hydrophilic polyurethane foam dressing containing ibuprofen (ibuprofen concentration: 0.5 mg/ cm2), Biatain-Ibu® (Coloplast A/S), on 122 patients with painful venous ulcers. Patients were randomised to receive either the Biatain-Ibu® or a standard Biatain foam dressing. The researchers concluded that there was no difference in dressing absorption capacity between the two compared dressings; however, the ibuprofen foam dressing was beneficial for persistent pain relief and reducing persistent and temporary wound pain intensity without compromising healing or safety. In 2019, researchers conducted a study with patients with partial thickness burns using Biatain-Ibu® (Coloplast A/S) and had very similar results (Lee et al, 2019).
Conclusion
Health professionals must always acknowledge how pain impacts their patient's quality of life in terms of depression, stress, anxiety, fear and social isolation.
Patients will always experience some element of pain from their wounds; however, this can be managed with careful and thorough ongoing assessment. Being aware of the type of pain experienced will enable the most appropriate analgesia to be prescribed. In addition to pharmacological strategies, ensuring the correct dressings are used in accordance with exudate level, to facilitate pain-free dressing changes, will aid in minimising patients’ pain. In addition, health professionals can use other adjuvant strategies, such as diversion therapy or allowing the patient to remove their own dressing, which some patients may find helpful.
However, the key message is that only the patient experiencing the pain can describe what level and severity of sensation they are feeling. This must always be believed and cannot be doubted by another person who is not having the same experience.
CPD reflective practice
- How confident are you around assessing wound pain?
- What strategies can you use to help manage wound pain during a dressing change?
- Reflect on your practice. Could you improve the way you acknowledge the impact of pain on your patients?
Key points
- Pain is an unpleasant sensation and results from the brain's response to actual or potential tissue injury
- Although most wounds are painful, the pain associated with chronic wounds, which may take 6-8 months to heal, can also lead to sleep disturbance, depression, anxiety, feelings of hopelessness and the inability to undertake basic activities of daily living
- Pain assessment should be performed regularly and not as a one-off initial assessment
- In addition to pharmacological strategies, ensuring the correct dressings are used in accordance with exudate level, to facilitate pain-free dressing changes, will aid in minimising patients’ pain