10 OstomyWound Management

Perspectives on Pain

OstomyWound Management

Pain is an unpleasant

physical and emotional

experience that plays a

key role in the lives of people

with chronic wounds.1-3 It is

well documented that the

majority of patients with

chronic wounds suffer from

moderate to severe pain for a

protracted period of time with

frequent exacerbations.4-8

Although pain often is associ-

ated with conditions intrinsic

to underlying etiologies (eg,

acute lipodermatosclerosis in

venous leg ulcers, Charcot

changes with diabetic foot

ulcers), trauma (pressure,

shear, and friction), chemical

irritation, infection, or inflam-

mation, spontaneous pain may occur due to sensitization

of nerve fibers.9 In studies conducted during dressing

changes, patients describe the most excruciating pain at

dressing removal as aggressive adhesives are peeled away

from fragile and damaged periwound skin.10-13 Increasing

evidence also validates pain with wound cleansing, espe-

cially when abrasive materials or forceps are used to

remove debris from the wound bed.3,14,15

To raise awareness and promote a systemic approach

to managing pain, Woo and Sibbald2 developed a

wound-associated pain (WAP) model that highlights

three key components: the wound, the cause, and the

patient (see Figure 1). First, the underlying cause of

the wound-associated pain must be treated.2,16 Second,

local wound care issues that may exacerbate wound-

associated pain must be addressed. These include tis-

sue trauma (dressing removal and wound cleans-

ing)5,17,18; moisture balance (too much moisture can

cause skin maceration and erosion while too little

moisture dries out the dressing that then tends to

adhere to wound bed)3; infection/inflammation

(increased pain is a warning sign for potential deep

wound infection)19,20; and patient-centered concerns

(eg, anxiety, depression, anticipation of pain).21-24

Meeting the Challenges of Wound-associatedPain: Anticipatory Pain, Anxiety, Stress, andWound Healing

Kevin Y. Woo, RN, MSc, PhD(C), ACNP, GNC(C)Clinical Scientist/Wound Care SpecialistWomen’s College Hospital Wound Healing ClinicToronto, Canada

Perspectives on Pain is a series of occasional articles provided to enhance knowledge and awareness of pain related to wounds and wound care.Supportfor this series is provided by Hollister Wound Care, Libertyville, Ill. This article was not subject to the Ostomy Wound Management peer-review process.

Figure 1. Wound-asso-ciated pain model.©2007 Woo & Sibbald

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While a plethora of advanced wound care products

and treatment modalities has been developed over the

years, little attention is paid to patient factors that can

modulate pain and wound healing. Experimental and

clinical studies of pain25,28 elucidate that the same stimu-

lus does not always evoke the same experience of pain.

Variability in pain perceptions can be influenced by

many contextual and psychological (patient-centered)

factors. Accumulating evidence has demonstrated that

anxiety in relation to anticipation of impending pain can

lead to increased self-reported pain intensity, reduced

pain tolerance, and decreased pressure pain thresh-

olds.29,30 With heightened anxiety, environmental and

somatic signals are brought to the patient’s attention,

sharpening the degree of sensory receptivity. Similar to

the concept of a self-fulfilling prophecy, the term nocebo

effect (versus placebo effect) is used to connote the phe-

nomenon in which pain is incurred or intensified by

patients’ anticipation or expectation.31-33

The Pathophysiology of Anticipated PainAnticipation of pain and associated anxiety are more

than psychological phenomena. They have been demon-

strated to trigger the activation of cholecystokinin, which

plays a crucial role in pain transmission.33 Neuroimaging

studies documented that the anterior cingulate cortex,

the prefrontal cortex, and the insula are activated during

the anticipation of pain, suggesting a specific neurocir-

cuitory connection. Anxiety also may reduce the

descending inhibition signals, allowing pain to gain

access through the “gate control mechanism” to the cen-

tral nervous system.34

How do anxiety and anticipation of pain affect wound

healing? Psychological stress as result of pain and anxiety

activates the hypothalamic-pituitary-adrenal (HPA) axis

and cortisol production. The hormone glucocorticoid

modulates immune cells by suppressing differentiation

and proliferation, down-regulating gene transcription

and reducing expression of cell adhesion molecules that

are essential for cell trafficking.35,36

Deficient inflammatory response will hamper the

body’s defense against invading organisms and removal

of debris from wound bed for tissue regeneration. Several

studies have demonstrated the association between stress

and impaired healing. Kiecolt-Glaser37 compared wound

healing in 13 women caregivers who had a relative with

Alzheimer’s Disease to 13 controls matched for age. Time

to achieve complete closure of biopsy-induced wounds

was 9 days longer in the caregiver versus control groups

due to caregiving stress (P <0.05). Marucha et al38 docu-

mented that the average complete wound healing time

was significantly longer in 11 students during stressful

examinations (P <0.001). Garg et al39 observed that skin

barrier recovery rate from damage caused by tape

stripping was significantly slower during a high versus

low stress period (P <0.001). Glaser and his team40

examined psychological stress and the levels of proin-

flammatory cytokines in experimentally-induced skin

blisters on the forearms of 36 women. Women who

reported high stress produced significantly lower lev-

els of IL-1alpha (P <0.03) and Il-8 (P <0.04). On the

other hand, chronic and repeated stress/pain may

attenuate the HPA axis feedback mechanism. The

result is excess inflammatory response and end-prod-

ucts (eg, MMPs) that stall wound healing.

In a cross-sectional study of patients with leg ulcers (n

= 190), Jones et al41 examined the relationships between

anxiety, living alone, mobility, exudate, and pain. Only

pain and anxiety were significantly related. Woo et al10

examined pain, anxiety, and anticipatory pain in 96

patients with chronic wounds. The subjects were asked

to rate their levels of anticipatory pain and actual pain

levels at different times during wound care using a

numerical rating scale. Anxiety was measured by

Spielberger’s State Anxiety Inventory.42 During dressing

change, patients rated cleansing and dressing removal

as the most painful. Consistent with previous findings,

the higher the anxiety before dressing change, the high-

er the anticipatory level of pain and the more intense

the pain expressed during the procedure (P = 0.000), a

significant correlation. Linear regression identified anx-

iety as a significant predictor of mean pain scores,

accounting for 25.7% of variance.

Implication for PracticeAnxiety-reduction techniques include relaxation,

music, touch therapy, visual stimulation, hypnosis,

stress-reducing strategies, guided imagery, behavioral

and cognitive therapy, and distraction. These tech-

niques have been suggested as options for managing

wound pain.43 In addressing anxiety and anticipation

of pain, the importance of the therapeutic relationship

September 2008 Vol. 54 Issue 9 11

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between patients and healthcare providers cannot be

underestimated. Clinicians must recognize that certain

individuals are more likely to overestimate pain, making

them susceptible to anxiety. Before initiating any wound

care procedures, adequate information tailored to indi-

vidual level of understanding should be provided. To

mitigate pain, it is important to:

• Engage patients, their families, and other caregivers

by talking about their pain and concerns about

debridement

• Empathize about the impact of pain

• Educate patients by explaining why the procedure

is required and how it is done

• Enlist their participation by allowing the patient to

actively participate during the procedure and call

time outs. (Table 1).44

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patient-focused toolkit. D.I.M.E. Pain and wound bed preparation: frompatient-centered concerns to D.I.M.E. Compliments of Molnlycke Healthcare,Gothenburg, Sweden. 2007:1-4.

2. Woo K, Sibbald G, Fogh K, et al. Assessment and management of persistent(chronic) and total wound pain. Int Wound J. 2008;5:205–215.

3. Woo KY, Harding K, Price P, Sibbald G. Minimising wound-related pain atdressing change: evidence-informed practice. Int Wound J. 2008;5(2):144–157.

4. Price PE, Fagervik-Morton H, Mudge EJ, et al. Dressing-related pain in patientswith chronic wounds: an international patient perspective. Int Wound J.2008;5(2):159–171.

5. Meaume S, Téot L, Lazareth I, Martini J, Bohbot S. The importance of painreduction through dressing selection in routine wound management: theMAPP study. J Wound Care. 2004;13(10):409–413.

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7. Nemeth KA, Harrison MB, Graham ID, et al. Understanding venous leg ulcerpain: results of a longitudinal study. Ostomy Wound Manage. 2004;50(1):34–36.

8. Günes UY. A descriptive study of pressure ulcer pain. Ostomy Wound Manage.2008; 54(2):56–61.

9. Woo KY, Sibbald RG. Chronic wound pain: a conceptual model. Adv SkinWound Care. 2008;21(4):175–188.

10. Woo K, Sadavoy J, Sidani S, Maunder R, Sibbald RG. The relationship betweenanxiety, anticipatory pain, and pain during dressing change in the older popu-lation. Presented at the CAWC Annual Conference. London, Ontario.November 1-4, 2007.

11. Szor JK, Bourguignon C. Description of pressure ulcer pain at rest and at dress-ing change. J Wound Ostomy Continence Nurs. 1999;26(3):115–120.

12. Price P, Fogh K, Glynn C, Krasner DL, Osterbrink J, Sibbald RG. Managingpainful chronic wounds: the Wound Pain Management Model. Int Wound J.2007;4(suppl 1):4–15.

13. Dykes PJ, Heggie R. The link between the peel force of adhesive dressings andsubjective discomfort in volunteer subjects. J Wound Care. 2003;12:260–262.

14. Briggs M. Examining equipment for wound care: the use of forceps and cottonwool in dressing packs. Accid Emerg Nurs. 1994;2:237–239.

15. Ernst A, Gershoff L, Miller P. Warmed versus room temperature for lacerationirrigation: a randomized clinical trial. South Med J. 2003;96:436–439.

16. Freedman G, Entero H, Brem H. Practical treatment of pain in patients withchronic wounds: pathogenesis-guided management. Am J Surg.2004;188:31–35.

17. Hollinworth H, Collier M. Nurses’ views about pain and trauma at dressingchanges: results of a national survey. J Wound Care. 2000;9:369–373.

18. Dykes PJ, Heggie R, Hill SA. Effects of adhesive dressings on the stratumcorneum of the skin. J Wound Care. 2001;10(2):7–10.

19. Gardner SE, Frantz RA, Troia C, et al. A tool to assess the clinical signs andsymptoms of localized infection in chronic wounds: development and reliabil-ity. Ostomy Wound Manage. 2003;49(4 suppl):24–29.

20. Landis S, Ryan S, Woo K, Sibbald RG. Infections in chronic wounds. In: KrasnerDL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Bookfor Healthcare Professionals, 4th edition. Malvern, Pa: HMPCommunications;2007:299–323.

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24. Roth RS, Lowery JC, Hamill JB. Assessing persistent pain and its relation toaffective distress, depressive symptoms and pain catastrophizing in patientswith chronic wounds: a pilot study. Am J Phys Med Rehabil. 2004;83:827–834.

25. Kenntner-Mabiala R, Andreatta M, Wieser MJ, Mühlberger A, Pauli P. Distincteffects of attention and affect on pain perception and somatosensory evokedpotentials. Biol Psychol. 2008;78(1):114–122.

26. Loggia ML, Mogil JS, Bushnell MC. Empathy hurts: compassion for anotherincreases both sensory and affective components of pain perception. Pain.2008;136(1-2):168–176.

27. Kut E, Schaffner N, Wittwer A, et al. Changes in self-perceived role identitymodulate pain perception. Pain. 2007;131(1-2):191–201.

28. Miller C, Newton SE. Pain perception and expression: the influence of gender,personal self-efficacy, and lifespan socialization. Pain Manag Nurs.2006;7(4):148–152.

29. Feeney SL.The relationship between pain and negative affect in older adults:anxiety as a predictor of pain. J Anxiety Disord. 2004;18(6):733–744.

30. Gore M, Sadosky A, Leslie D, Sheehan AH. Selecting an appropriate medicationfor treating neuropathic pain in patients with diabetes: a study using the UKand Germany mediplus databases. Pain Pract. 2008;8(4):253–262.

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34. Melzack R. Recent concepts of pain. J Med. 1982;13(3):147–160.35. Blackburn-Munro G. Hypothalamo-pituitary-adrenal axis dysfunction as a

contributory factor to chronic pain and depression. Curr Pain Headache Rep.2004;8(2):116–124.

36. Sternberg EM. Neural regulation of innate immunity: a coordinated nonspe-cific host response to pathogens. Nat Rev Immunol. 2006;6(4):318–328.

37. Kiecolt-Glaser JK, Marucha PT, Malarkey WB, Mercado AM, Glaser R. Slowingof wound healing by psychological stress. Lancet. 1995;346(8984):1194–1196.Comment in: Lancet. 1996;347(8993):56.

38. Marucha PT, Kiecolt-Glaser JK, Favagehi M. Mucosal wound healing isimpaired by examination stress. Psychosom Med. 1998;60(3):362–365.

39. Garg A, Chren MM, Sands LP, et al. Psychological stress perturbs epidermalpermeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137(1):53–59. Comment in:Arch Dermatol. 2001;137(1):78–82.

40. Glaser R, Kiecolt-Glaser JK, Marucha PT, MacCallum RC, Laskowski BF,Malarkey WB. Stress-related changes in proinflammatory cytokine productionin wounds. Arch Gen Psychiatry. 1999;56(5):450–456..

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12 OstomyWound Management

TABLE 1THE FOUR E’S TO ADDRESS PAIN

Engaged Ask something about the patient other than the reason for the visit

Empathized not True concern and sympathized understanding for the

patient’s pain Educated Explain the provider

perspective. Listen to the patient perspective

Enlisted Negotiate a compromise

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