PAIN & QUALITY OF LIFE

Pain is a sensory and emotional experience that is described by whatever the patient says it is. Pain is a common concern that has a profound effect on patients with chronic wounds. Substantial evidence indicates that a large portion of patients with chronic wounds experiences constant and considerable levels of pain. The impact can be devastating and agonizing. As a result of pain, patients often limit daily activities of daily living and social activities leading to depression and diminished quality of life. Wound associated pain involves interplay of many systemic, local, and patient factors that necessitate a systematic approach. Woo and Sibbald proposed a framework that integrates the key concepts from wound bed preparation into the comprehensive management of wound related pain. Pain and wound cause The underlying pathology of the wound must be addressed to effectively management wound related pain.

• Pressure ulcer: friction, shear, deep tissue injury, incontinence related lesions
• Leg ulcers: edema of venous disease, phlebitis, lipodermatosclerosis
• Diabetic foot ulcers: neuropathy, deep tissue destruction
• Ischemic ulcer: claudication, vasospasm, reperfusion injury

Patient centered concerns (factors) Pain is more than a detection of noxious stimulation. Psychological factors such as anxiety, depression, sense of powerlessness may affect the experience of pain. Pain must be interpreted within a context that integrate patients’ value system, expectation, and past experiences of pain.

Local wound care factors (DIME) Debridement and tissue trauma The different debridement methods are accompanied with varying degree of pain and discomfort. Sharp/surgical and mechanical debridement methods are most likely to induce pain. Alternatively, autolytic, enzymatic, and biological debridement should be considered.

Infection/Inflammation Emergence or a sudden increase in pain is a warning sign. It has been demonstrated that increased pain is a valid and specific sign suggesting the presence of wound infection. The use of mnemonic NERDS and STONEES may help clinicians to identify other local wound characteristics associated with superficial or deep wound infection.

Moisture balance Moisture is essential for wound healing. Excess wound fluid can spill over to wound edges causing maceration to periwound skin and pain. In contrast, dried out dressing material may adhere to the wound causing trauma upon its removal. An ideal dressing be able to remove excess fluid while maintaining the wound base moist, atraumatic, and be able to promote comfort in between dressing changes.

Identify and Treat the Cause		Level of Evidence
1	Identify and treat the cause of the chronic wound with the patient’s active participation	Not Assessed
2	Increased wound pain requires reassessment of underlying conditions or etiologies for treatable causes. Increased wound pain may be an important clinical symptom of infection or inflammation	Not Assessed
Address patient-centered Concerns		Level of Evidence
3	Involve and empower patients and caregivers to consider different options for wound pain management to optimize pain control	Not Assessed
4	Assess / control pain to optimize activities of daily living. Prevent and/or minimize anticipatory and procedural wound pain by using appropriate pain management techniques	Not Assessed
Provide Local Wound Care		Level of Evidence
5	Cleanse wounds gently with warm saline or water. Avoid the use of abrasive wipes and cold solutions	Not Assessed
6	Select an appropriate method of wound debridement for each wound and include the potential for causing wound related pain.	Not Assessed
7	Choose dressings that minimize trauma/pain with application and removal.	Not Assessed
8	Initiate empiric systemic antibiotic therapy for infected wounds and critically colonized wounds in patients with diabetes, and individualize therapy once culture and sensitivity data are available.	Not Assessed
Provide Organizational Support		Level of Evidence
9	Communicate, educate and implement the wound pain management plan verbally and with documentation to the patients, caregivers and the interprofessional team	Not Assessed

Essential Publications
2	Chronic wound pain	Quality Indicator	Type:
Woo KY, Sibbald RG. Chronic wound pain: A conceptual model. Adv Skin Wound Care 2008;21(4):175-188.
The purpose of this article is to provide a model for the assessment and treatment of chronic wound-related pain based on the wound bed preparation paradigm. It examines in depth key aspects associated with wound pain such as patient concerns, the cause of the wound and the pain, related complications, and local wound factors.
3	Quality of life	Quality Indicator	Type: Systematic review
Persoon A, Heinen MM, van der Vleuten CJM, de Rooij MJ, van de Kerkhof PCM, van Achterberg T. Leg ulcers: A review of their impact on daily life. Journal of Clinical Nursing 2004;13(3):341-354.
In this review, the effect of having leg ulcers on patient’s quality of life was examined. Negative impact on physical, psychological, and social functioning were reported, which correlates with a significantly poorer quality of life in comparison with healthy people. Major aspects that clinicians need to address better are patient’s pain levels and lack of mobility.
4	Quality of life, hard-to-heal wounds	Quality Indicator	Type: Systematic review
EWMA. Hard-to-heal wounds: A holistic approach. EWMA Position Document 2008.
In this position document by the European Wound Management Association (EWMA), the effect of psychosocial factors on the healing of hard-to-heal wounds is examined. Papers by Vowden et al, Moffatt et al, and Romanelli et al are included in this document. Vowden et al examine the effect of physical, bacteriological, biochemical, and patient-related factors on delayed wound healing, and in particular emphasize the impact that psychosocial factors have on healing. Moffatt et al analyze the interrelationship between delayed wound healing and psychosocial factors such as anxiety, depression, sleep deprivation, and socioeconomic status. Romanelli et al look at how high costs of treatment for hard-to-heal wounds can have a negative impact on the healing time, leading to complications and longer healing time. The importance of early recognition of the wound to minimize complications and healing time and prevent the patient’s quality of life from being negatively impacted is stressed in these three papers.
5	Pain at dressing change	Quality Indicator	Type: Narrative Review
Woo KY, Harding K, Price P, Sibbald G (2008). Minimising wound-related pain at dressing change: evidence-informed practice. Int Wound J 5: 144-157.
It is important to consider wound-related pain control holistically from local wound bed factors and dressing selection to patient-centred concerns and the treatment of the wound cause. The removal of the silicone dressing was less painful compared with dressings that required higher peel force (n=24, P