CLIN CAL REVIEW

Skin cooling, pain and chronicwound healing progressionJeannette MuldoonJfiiiinclic Miiliiooii /.v /Vi'/ixv/c,

Aftiiv HcaUluarv

Svri'icvs (ClUmal).Eiihiil:

The coniplex mechanism of wotind heahn^ isdependent on many factors (Gottrtip, 20(11). andmost practitioners tisc well-known nierliods to

detertnine accurate assessment and to implement the opti-mtitn environment tor wotind healing. However, it has beensuggested that not enough is kiiown about some ot tbe tac-tors that contribute to wound bealing (Motlatt, 21)04),Thereare still many areas where tbeory does not always tnatch thepractical situation and confiision often arises when all factorsare not considered.

Two factors about vvbicb there are contlittint; beliefs areskin cooling and pain. It is received wisdom that skin eool-ing will reduce the rate ot ceU division and so slow healing.Does this mean a wound should never be cooled? Thisarticle examines sotne ot the evidence.

Pain is poorly understood in relation to chronic wounds,and is rarely dealt with in a systematic way,Yet it may affectwound healing in direct and indirect ways, which this articlewill examine.

Skin coolingConcerns about excessive cooling and the possible effectson wound progression bave led to the development of sometherapies that are based on the warming of the wound bedto encourage granulation.

Certainly,, research confirms tbat cell division and theaction of fibroblasts is reduced at temperatures below 33°C{Lock, 1979), and researcb confirms tbat wounds cool downduring dressing changes. A study by McGuiness et al (2004)examined these temperature variations. The researchersmeasured wound bed temperature before and after dress-ing change, and external dressing temperatures from tbetime the dressing was applied until it reached pre-changetemperature. Wound bed temperatures dropped an averageof 2°C during dressing changes, and took an average of 23minutes to returti to normal.

However, most studies of this nature have concentratedon acute wounds, whicb behave differently from chronicwounds in terms of cellular and biochemical activity'(Moore, 2005). In the Lock study, tbe wounds were eithertraumatic or caused by surgical debridenient .iiid rangedfrom about 4—12 days old.

The question to ask is, tbereforc, does temporary skincooling necessarily have an impact on chronic wound beal-ing? When deciding on treatment methods, should tempera-ture be considered in isolation to other factors? Or are there

situations where skin cooling can have a beneficial effect?Tbese qtiestions need to be asked wben critically assessingthe aims of management and tbe needs of the patient.

One area where skin cooling has a demonstrable positiveetfect is in reducing pain. When faced with a patient witha hot, inflamed, painful wound, the clinician may find ithard to justify avoiding a product that can provide a cool-ing, soothing remedy, Cellulitis, btirns and radiotherapy skindamage all respond very well to skin cooling, pro\'idingnuicb-needed pain relief to the sufferer (Wilkinson, 2004).Wet wrapping techniqties using cool, wet bandages havebeen the mainstay in the management of acute eczema inchildren (Bcattie, 2005). Another efTective (thougb now lesscommon) treatment is the apphcation ot cool zinc pastebandages, which when itsed in conjunction witb sustained,graduated compression are not only comfortable for tbepatient, but also a useful topical preparation for varicose skinconditions (Cameron, 1998).

Cooling dressings have recently been shown to bave abeneficial impact on pain in cbronic wounds. Young andHampton (2005) examined the effects of a hydrogel onpain in leg ulcers. Two pilot studies and a patient auditevaluated the effectiveness of a sheet hydrogel dressing inreducing pain by cooling atid soothing, and by batbing thenerve endings in a moist environment. Patients describedvariotis pain types, and assessment was based on acbe, burnand sharp pain. Although such evaluations are subjective,statistically significant reductions in pain were identifiedwben using the dressing.

Young and Hampton speculated that 'the reduction ofpain depended mainly on the inhibition of local inflamma-tory changes', and it was suggested that there was potentialfor the dressing 'to dampen the inflammatory response tbatcreated pain'.

ABSTRACTThere are many areas of wound care where theory does not always match

the practical experiences of the patient. This article discusses the effects

of two factors - skin cooling and pain - on chronic wound healing, and the

role of pain and inflammation on the overall wound healing process.

KEYWORDSTemperature change• Concordance

Pain • Inflammation • Wound healing

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CLINICAL REVIEW

Wound painWound pain has been the subject of many discussions andstudies m recent years. Pam m wounds can arise from sev-eral sources, including adherence of dressings and bacteridinfections. Most recent investigations have concentrated onthe pain experienced during traumatic dressing removal (e.g.Hollinwortb, 2002). This area is one that can be controlledeasily by the practitioner who decides on the treatment,and there are now many treatment regimes that can beimplemented to minimize this trauma, such as the use ofnon-adherent dressings.

Just as pain is being recognized as a relevant concern inwound care, it is being set in the wider context of qual-ity of hfe for people with vvotinds. The Enropcan WoundManagement Association has published a position document(EWMA. 2002) which highlights the need to recognizeimprovements in quality of life in terms of pain, maceration,tratnna and comfort, without the previously heavy relianceon complete wound healing. It is well-doctiniented thatpain reduction occurs with effective wound healing treat-ment (Hollinworth. 1999). but there is now also evidenceto show that effective healing can occur witb pain reduc-tion (Hampton, 2004),Tiie effects of pain on overall woundhealing can be far-reachmg when certain psychological andphysiological changes take place.

Effects of painTiie gate control theory (Godfrey, 2005) suggests that injuryand pain influence homeostasis and behavioural activity,reinforcing the relationship between stress and pain withresulting adverse efTects on the immune system. For exam-pK', correlation between stress and delayed wound healing asa result of a prolonged inflammatory stare was discussed ina case study on stress response in a paraplegic patient withpressure ulcers (Jones, 2003). Much bas also been writtenabout tbe effects of tbe anticipation of pain, especially unre-lieved pain in patients who has already experienced a painflilepisode (Mangwendeza, 2002).

Low self-esteem and depression caused by a non-healingor malodorous wound can often be the cause of delays inthe healing process (Budgen. 2004; Charles. 2004).This may

PAIN

Inflammation

DELAYSin

HEALING

Problems withConcordance

be related to the release of stress hormones, which can delayhealing (Young and Hampton, 2005). When sleep depriva-tion sets in as a result of persistent pain, the stress hormonecortisol is released, and this bas an impact on healing: directhnks between stress and tbe immune system have beennoted in several studies higblightcd by Jones (2003). Sobegins the vicions cycle of pain causing sleeplessness, wbichin turn delays bealing. leading to yet more pain from theunhealed wotind, and so on {F{^iirc I).

Pain-related problems with assessmentand concordancePam IS not restricted to wounds, and may indirectly affectwound heahng. Often physical pain is subjective and difficultto measure (Coyle, 20lO), however, the "vvatl of pain" that isexperienced by some patients may cause confiision and ablurring of systemic symptoms which can be indistingtiisha-ble ffom local wound p.iin.The presence of associated paiiifiilconditions also complicates tbe assessment process, especiallyin areas such as leg ulcers where painful iscbaemia can co-exist alongside wound pain (Hofinan and Cooper, 2005).

If a patient is in a great deal of pain, it is often difficult forthe assessor to obtain a coherent history in order to makethe correct diagnosis, and there bave been cases when thelimb has been too painful to allow a Doppler assessment tobe conducted in order to establish the vascular status beforethe application of compression therapy (Collins, 2005). Inthis case study, constant wound pain meant it was not pos-sible for tbe patient to tolerate the necessary compression,resulting in tbe persistence of venous hypertension, and theulcer failed to heal. Once tbe pain had been reduced witha pain-reiieving dressing, tbe patient was able to tolerate tbecompression bandage and the wound progressed to bealing.

This case shows how local wound management, coupledwitb a systemic approacb, pro\'ides tbe best otitcome for tbepatient who might otberw ise have been labelled "non-corcord-ant". Previous bad experiences of ceitain treatments may affectbelief in the current treatment and the practitioner (Motfatt,2004), I'ractitioners now agree that giving a patient somecontrol over their pain relief treatments will improve theirdiy-to-day quality of life (Ariiiitage and Roberts, 2004),

Patients often find it difficnlt to follow tbe advice givenby tbe nurse because of tbe overwhelming pain that diey areexperiencing (Edwards. 2003). In patients witb venous insuf-ficiency, venons return is promoted with good ankle mobility'(Lindsay, 2004) and correct exercising, bnt this is not alwayspossible wben severe pam inhibits mobility'. As in the casediscussed above, the correct compression system, tbe sympa-thetic ear of tbe practitioner and sound patient education allplay a vit.il role in helping patients to accept and follow theprescribed treatment (White. 2005). The knock-on effect ofconcordance with compression tberapy and effective mobil-it\' will be reduction of oedema, whicb in itself can be a causeof pain, by 'stretching' the tissues and reducing the supply ofntitrieiits and blood to the wound (1 lampton. 2flO4).

Effects of delayed healingPain is the result of a comple.x interplay of chemical messen-

S24 Wound Care, March 200b

CLINICAL REVIEW

gers. Excessive pain mediators, including pro-inflammatoryinctiiaturs. .iir known to impede healing (Clay and Chen,21)1)5). Clay and Chen have reviewed the consequenceson healinj^ of indirect pain mediators such as bradykinin.prostaglandins, leukotrienes, nerve growth tactor, histamineand serotonin, which sometimes interact with each other toamphf ' their effects (C!ay and Chen. 2005). Tiiese interac-tions have a major role to play in blood flow abnormalities,inflammation, tissue breakdown ,ind pam geneiatiuii.

Inflammation and exudare play a vital role in the woundhealing process (Beldon, 2(101; Grabam, 2)104). It is weli-documented that wound healing follows a set pattern ofintlammation, proliferation, granulation, maturation andcontraction. These stages should occur within certain timescales. The pmblem of the chronic wound occurs when thewound tails to progress through tbe stages to ftill healing,and the most common stage that is prolonged is the inflam-matory stage leading to excess inflammation and exudate.

Inflammation, excess slough and exudate can lead to thep!-odnction of inflammatory mediators sucb as histaminewhich, in excess, can turther delay healing. If the woundfails to heal and remains in the inflammatory stage, tbe risksof infection are increased. Increased levels of exLidate can beanother source of pain when maceration and excoriationaffect the peri-wound area (Fletcher, 2003). Dressings thataddress the moisture balance are tbe treatment of choice, butif the underlying cause of the infection and inflammationare not identified and treated tben these are simply short-term measures. Protracted inflammation manifests itself inan increased number of inflammatory' lenkocytes with aresultant release of tissue-damaging proteinases (Hart, 2002).and this continued inflammation and infection will result innew episodes of pain. In this way the pain cycle continueswith the possible consequences of a static wound and a verydepressed patient, leading to flirther exacerbation of pain.

To break the pain cycle it is essential that all treatmentregimes are considered.This may include the application ofa cooling prtiduct, which would not only soothe tbe inflam-mation within the wound, but also influence tbe patient'spsychological state, leading to increased immunity and heal-ing Clones, 2003; Clay and Chen, 20(15)

ConclusionIt is becoming evident that patients with chronic painfiilwounds aa' being dcilt a dotibie blow. Not only are they hav-ing to endure debilitating, depressing episodes of pain, but theyalso run the risk of protracted. non-he.Jing wounds whichwill continue to cause pain tor as long as they are present.The management ot pain is a ditRcult aira tor practitioners,as certain tvpes of pain may never be resolved, and the prac-titioner needs to accept that palliative care may be the onlyoption. Greater awareness of wound pain and its effects onheding, combined with etfecrive management regimes thatmdudt' topical and systemic intervention have the poteiiti d toimprove patient qti;i]ir\- ot lite and healing rates. B)CN

DvcLinjtioii of intacs': lite atitltor is iin etiiployev ojActifit I Icnllitiiirc

Lid. btii ihii ariicic is ttoi sponsored hyAilivd Heahhdtrv Lid

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KEY POINTS*Skin cooling does not always delay healing.

•Pain assessment is essential for effective diagnosis and treatment.

• Pain often affects concordance.

• Pain has a significant effect on wound healing not just on quality of life.

• It may be possible to interrupt the pain/delayed wound healing/pain cycle

to encourage wound progression.

n

Wound Care, March 2006 S25