Background

Chronic wound pain is a complicated condition with both physical and psychological aspects.¹ The magnitude of pain is usually contingent on the depth of the wound and whether an infection is present. Nevertheless, providing adequate pain relief can be challenging due to wound management’s multi-faceted nature.² It is essential to understand the physiology of pain, the types, its impact on healing, assessment techniques, and various wound care approaches to develop a comprehensive care plan for patients with wounds.³

Pain Physiology

The peripheral transmission of pain occurs through transduction and transmission. Transduction involves the production of electrical signals at pain nerve endings, while transmission occurs when the peripheral nervous system propagates electric signals.^4,5 It is essential to accurately determine the pathway and category of the pain related to the wound when a patient reports it, as this will allow for the appropriate management of the pain.

Pain Pathway

Nociceptive pain

Nociceptive pain is the body’s normal physiological response to a harmful stimulus. The core role of nociceptive pain is to alert the individual to injury.^5,6

Neuropathic pain

Neuropathic pain occurs due to damage or dysfunction to the nervous system, such as nerve damage from trauma or infection. Signals traveling through aberrant pathways typically result in inappropriate or amplified pain.^5,6 This form of pain increases patient risk for chronic pain.⁶

What Are the Categories of Pain?

In addition to being either nociceptive or neuropathic, pain can fall under several categories. Patients with wounds may experience background pain, incident pain, procedural pain, or operative pain.⁶

Background pain

Background pain is persistent, originating from the injury’s root cause and local (ie, infection) and pathological (ie, neuropathy) factors. Patients may often experience background pain at rest.^3,6 In patients with wounds, background pain may be related to infection and a subsequent prolonged inflammatory response.⁶ This reaction results in the release of inflammatory mediators, which in turn activate the synthesis of enzymes and free radicals, damaging the tissue.⁷ Swelling, direct stimulation of peripheral pain receptors by mediators, and tissue damage can all cause pain. This prolonged inflammation may damage the patient’s central nervous system and pain receptors, increasing sensitivity and heightening perceptions of pain.⁷

Incident pain

Incident pain, or breakthrough pain, occurs when a patient develops an injury during a normal voluntary or involuntary movement. Incident pain is typically brief and intense, compared to background pain which is usually ongoing and less severe. Activities of daily living, like the transfer of a patient or wound trauma from dressing slippage, cause breakthrough pain. This pain occurs when a patient with stable, treated, or persistent pain experiences a transient increase in pain due to patient movement or activity.^3,6 Because of the differences in incident and background pain, it is vital to note that different analgesics should be used.⁶

Procedural pain

Procedural pain is distressing physically and mentally, often occurring due to medical tests or treatments. This pain occurs during common procedures without injury or trauma to the wound, such as removing or applying a dressing and cleansing.^3,6

Operative pain

Operative pain occurs when a specialist performs an intervention on a wound that requires a local or general anesthetic. In wound care, these procedures may include surgical or mechanical debridement.^3,6

The Consequence of Pain and Wound Healing

If pain is not properly managed, the nervous system can become overly sensitive to even the slightest sensations, possibly forming “a pain memory” in the central nervous system. Research has indicated a strong correlation between stress, anxiety, and the intensity of pain felt by an individual. These emotions lead to an increase in cortisol and catecholamine levels, which subsequently impact immunity and oxygen levels in the body, hindering wound healing.^3,8,9

• Cortisol has an inhibitory effect on the immune system, which can decrease white blood cell activity, reduce fibroblast growth, and weaken the structural integrity of wounds, resulting in a prolonged healing time.^3,8
• Catecholamines can cause a narrowing of the small arteries.^3,8,10

The Result of Pain on Quality of Life

Pain can affect various aspects of a patient’s quality of life, including social relationships, job performance, leisure activities, and mental health. People with chronic wound pain may suffer from disrupted sleep, which further impacts health and well-being. Furthermore, persistent pain can lead to feelings of doubt, loneliness, and diminished self-worth.¹¹

Pain Assessment

Pain assessment should always involve the patient, with their feedback as the definitive indication of their experience. Wound care professionals should take special consideration when treating elderly or cognitively impaired individuals since a greater level of understanding is required. The World Union of Wound Healing Societies released a consensus document with strategies to help guide the management of pain related to wounds. These strategies include the following⁶:

• Ask the patient about the quality, location, and pain triggers.
• Measure pain intensity using the Wong-Baker FACES Scale, Visual Analogue Scale, Numerical Rating Scale, or Verbal Rating Scale.
• Advise the patient to keep a pain diary to record continuous pain scoring
• Monitor pain before, during, and after a procedure or treatment.
• Look for indicators of inflammation and infection, such as delayed healing, wound deterioration, erythema, heat, purulence, and odor.
• Assess the condition of the surrounding skin for evidence of dressing adherence, excessive exudate, necrosis, or maceration.

Wound Management Strategies

The following are some wound care techniques that may mitigate the level and duration of pain experienced by patients:

• Treat underlying etiology or cause.
• Address any neighboring issues or local factors that might cause discomfort (ie, pressure, maceration, infection, dryness or excess exudate, trauma, edema, ischemia, and maceration of the surrounding skin).
• Choose dressings that minimize the risk of periwound maceration and do not cause pain or trauma during application or removal. For example, wet-to-dry saline dressing use might be painful.¹²
• Non-pharmaceutical pain management techniques include distraction techniques, calming music, breathing exercises, and relaxation techniques. Additionally, a calm and quiet environment aids in lowering the signs of stress and tension, which can exacerbate the pain of a wound.⁸
• Evaluate the need for both non-pharmaceutical and pharmacological pain-relieving therapies. WHO recommends 3 steps known as the analgesic pain ladder. In response to mild pain, step 1 calls for using non-opioids and adjuvant analgesics. Step 2 indicates the use of a weak opioid in combination with adjunct analgesics or adjuvants if the patient is experiencing mild to moderate pain. In Step 3, WHO recommends clinicians incorporate a strong opiate with non-opioid and adjunct analgesic to manage moderate to severe pain.¹³
• Encourage and enable patients to participate in their own pain management.
• Ensure that every patient has access to effective pain relief for wounds.

Conclusion

Pain undeniably affects wound care management practice, making it vital. However, clinicians may overlook pain as a factor during wound care and healing. Unresolved pain harms the patient's quality of life and healing efficacy, thus necessitating clinicians to adopt effective wound care management strategies.

References

1. Frescos N. Assessment of pain in Chronic wounds: A survey of Australian health care practitioners. Int Wound J. 2018;15(6):943-949. doi:10.1111/iwj.12951
2. Suzuki K, Lockhart R, & Birnbaum Z. Principles In Pain Management For Wound Care Patients. Podiatry Today. 2016;29(8). https://www.hmpgloballearningnetwork.com/site/podiatry/principles-pain-….
3. Bechert K, Abraham SE. Pain management and wound care. J Am Col Certif Wound Spec. 2009;1(2):65-71.doi:10.1016/j.jcws.2008.12.001
4. Cohen M, Quintner J, Rysewyk S. Reconsidering the International Association for the Study of Pain definition of pain. Pain Rep. 2018;3(2):e634. doi:10.1097/PR9.0000000000000634
5. Gomes LR, Leão P. Recent approaches on signal transduction and transmission in acupuncture: a biophysical overview for medical sciences. J Acupunct Meridian Stud. 2020;13(1): 1-11. https://doi.org/10.1016/j.jams.2019.11.003
6. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004;3(1):1-8. https://www.woundsinternational.com/download/resource/6028
7. Cutting KF, White RJ, Mahoney P. Wound infection, dressings and pain, is there a relationship in the chronic wound? Int Wound J. 2013;10(1):79-86. doi:10.1111/j.1742-481X.2012.00947.x
8. Serena T, Yaakov R, Aslam S, Aslam R. Preventing, minimizing, and managing pain in patients with chronic wounds: challenges and solutions. Chronic wound care manag res. 2016;3:85-90. doi:10.2147/cwcmr.s85463
9. Exploring the effects of pain and stress on wound healing. Advances in Skin & Wound Care. 2012;25(1):45-46. doi:10.1097/01.asw.0000410690.67728.35
10. Woo KY. The relationship between anxiety, anticipatory pain, and pain during dressing change in the older population. J Wound Ostomy Continence Nurs. 2008;35(3):72. doi:10.1097/01.won.0000319458.56556.9a
11. Newbern S. Identifying Pain and Effects on Quality of Life from Chronic Wounds Secondary to Lower-Extremity Vascular Disease: An Integrative Review. Adv Skin Wound Care. 2018;31(3):102-108. doi:10.1097/01.ASW.0000530069.82749.e5
12. Shi C, Wang C, Liu H, et al. Selection of appropriate wound dressing for various wounds. Front Bioeng Biotechnol. 2020;8:182 doi:10.3389/fbioe.2020.00182 https://www.frontiersin.org/articles/10.3389/fbioe.2020.00182/full
13. Who analgesic ladder - statpearls - NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK554435/. Accessed January 24, 2023.

About the Author

Thanoon Thabet, BSN, RN, WTA-C is an early career Clinical Nurse who holds a Wound Treatment Associate certification (WTA-C) through the Wound, Ostomy, and Continence Nursing Certification Board (WOCNCB). His clinical focus is adult-geriatric medical and surgical nursing, with plans to pursue future full tri-specialty certification in WOC Nursing. He values nursing mentorship and is passionate about engaging in scholarship activities such as evidence-based practice, academic advancement, and nursing leadership.