skin cooling, pain and chronic wound healing progression

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CLIN CAL REVIEW

Skin cooling, pain and chronic wound healing progressionJeannette MuldoonJfiiiinclic Miiliiooii /.v /Vi'/ixv/c, Aftiiv HcaUluarv Svri'icvs (ClUmal). Eiihiil:

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he coniplex mechanism of wotind heahn^ is dependent on many factors (Gottrtip, 20(11). and most practitioners tisc well-known nierliods to detertnine accurate assessment and to implement the optimtitn environment tor wotind healing. However, it has been suggested that not enough is kiiown about some ot tbe tactors that contribute to wound bealing (Motlatt, 21)04),There are still many areas where tbeory does not always tnatch the practical situation and confiision often arises when all factors are not considered. Two factors about vvbicb there are contlittint; beliefs are skin cooling and pain. It is received wisdom that skin eooling will reduce the rate ot ceU division and so slow healing. Does this mean a wound should never be cooled? This article 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 affect wound healing in direct and indirect ways, which this article will examine.

situations where skin cooling can have a beneficial effect? Tbese qtiestions need to be asked wben critically assessing the aims of management and tbe needs of the patient. One area where skin cooling has a demonstrable positive etfect is in reducing pain. When faced with a patient with a hot, inflamed, painful wound, the clinician may find it hard to justify avoiding a product that can provide a cooling, soothing remedy, Cellulitis, btirns and radiotherapy skin damage all respond very well to skin cooling, pro\'iding nuicb-needed pain relief to the sufferer (Wilkinson, 2004). Wet wrapping techniqties using cool, wet bandages have been the mainstay in the management of acute eczema in children (Bcattie, 2005). Another efTective (thougb now less common) treatment is the apphcation ot cool zinc paste bandages, which when itsed in conjunction witb sustained, graduated compression are not only comfortable for tbe patient, but also a useful topical preparation for varicose skin conditions (Cameron, 1998). Cooling dressings have recently been shown to bave a beneficial impact on pain in cbronic wounds. Young and Hampton (2005) examined the effects of a hydrogel on pain in leg ulcers. Two pilot studies and a patient audit evaluated the effectiveness of a sheet hydrogel dressing in reducing pain by cooling atid soothing, and by batbing the nerve endings in a moist environment. Patients described variotis pain types, and assessment was based on acbe, burn and sharp pain. Although such evaluations are subjective, statistically significant reductions in pain were identified wben using the dressing. Young and Hampton speculated that 'the reduction of pain depended mainly on the inhibition of local inflammatory changes', and it was suggested that there was potential for the dressing 'to dampen the inflammatory response tbat created pain'.

Skin coolingConcerns about excessive cooling and the possible effects on wound progression bave led to the development of some therapies that are based on the warming of the wound bed to encourage granulation. Certainly,, research confirms tbat cell division and the action of fibroblasts is reduced at temperatures below 33C {Lock, 1979), and researcb confirms tbat wounds cool down during dressing changes. A study by McGuiness et al (2004) examined these temperature variations. The researchers measured wound bed temperature before and after dressing change, and external dressing temperatures from tbe time the dressing was applied until it reached pre-change temperature. Wound bed temperatures dropped an average of 2C during dressing changes, and took an average of 23 minutes to returti to normal. However, most studies of this nature have concentrated on acute wounds, whicb behave differently from chronic wounds in terms of cellular and biochemical activity' (Moore, 2005). In the Lock study, tbe wounds were either traumatic or caused by surgical debridenient .iiid ranged from about 412 days old. The question to ask is, tbereforc, does temporary skin cooling necessarily have an impact on chronic wound bealing? When deciding on treatment methods, should temperature be considered in isolation to other factors? Or are there

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

Wound Care, March 200b

S21

CLINICAL REVIEW

Wound painWound pain has been the subject of many discussions and studies m recent years. Pam m wounds can arise from several sources, including adherence of dressings and bacterid infections. Most recent investigations have concentrated on the pain experienced during traumatic dressing removal (e.g. Hollinwortb, 2002). This area is one that can be controlled easily by the practitioner who decides on the treatment, and there are now many treatment regimes that can be implemented to minimize this trauma, such as the use of non-adherent dressings. Just as pain is being recognized as a relevant concern in wound care, it is being set in the wider context of quality of hfe for people with vvotinds. The Enropcan Wound Management Association has published a position document (EWMA. 2002) which highlights the need to recognize improvements in quality of life in terms of pain, maceration, tratnna and comfort, without the previously heavy reliance on complete wound healing. It is well-doctiniented that pain reduction occurs with effective wound healing treatment (Hollinworth. 1999). but there is now also evidence to show that effective healing can occur witb pain reduction (Hampton, 2004),Tiie effects of pain on overall wound healing can be far-reachmg when certain psychological and physiological changes take place.

be related to the release of stress hormones, which can delay healing (Young and Hampton, 2005). When sleep deprivation sets in as a result of persistent pain, the stress hormone cortisol is released, and this bas an impact on healing: direct hnks between stress and tbe immune system have been noted in several studies higblightcd by Jones (2003). So begins the vicions cycle of pain causing sleeplessness, wbich in turn delays bealing. leading to yet more pain from the unhealed wotind, and so on {F{^iirc I).

Pain-related problems with assessment and concordancePam IS not restricted to wounds, and may indirectly affect wound heahng. Often physical pain is subjective and difficult to measure (Coyle, 20lO), however, the "vvatl of pain" that is experienced by some patients may cause confiision and a blurring of systemic symptoms which can be indistingtiishable ffom local wound p.iin.The presence of associated paiiifiil conditions also complicates tbe assessment process, especially in areas such as leg ulcers where painful iscbaemia can coexist alongside wound pain (Hofinan and Cooper, 2005). If a patient is in a great deal of pain, it is often difficult for the assessor to obtain a coherent history in order to make the correct diagnosis, and there bave been cases when the limb has been too painful to allow a Doppler assessment to be conducted in order to establish the vascular status before the application of compression therapy (Collins, 2005). In this case study, constant wound pain meant it was not possible for tbe patient to tolerate the necessary compression, resulting in tbe persistence of venous hypertension, and the ulcer failed to heal. Once tbe pain had been reduced with a pain-reiieving dressing, tbe patient was able to tolerate tbe compression bandage and the wound progressed to bealing. This case shows how local wound management, coupled witb a systemic approacb, pro\'ides tbe best otitcome for tbe patient who might otberw ise have been labelled "non-corcordant". Previous bad experiences of ceitain treatments may affect belief in the current treatment and the practitioner (Motfatt, 2004), I'ractitioners now agree that giving a patient some control over their pain relief treatments will improve their diy-to-day quality of life (Ariiiitage and Roberts, 2004), Patients often find it difficnlt to follow tbe advice given by tbe nurse because of tbe overwhelming pain that diey are experiencing (Edwards. 2003). In patients witb venous insufficiency, venons return is promoted with good ankle mobility' (Lindsay, 2004) and correct exercising, bnt this is not always possible wben severe pam inhibits mobility'. As in the case discussed above, the correct compression system, tbe sympathetic ear of tbe practitioner and sound patient education all play a vit.il role in helping patients to accept and follow the prescribed treatment (White. 2005). The knock-on effect of concordance with compression tberapy and effective mobilit\' will be reduction of oedema, whicb in itself can be a cause of pain, by 'stretching' the tissues and reducing the supply of ntitrieiits and blood to the wound (1 lampton. 2flO4).

Effects of painTiie gate control theory (Godfrey, 2005) suggests that injury and pain influence homeostasis and behavioural activity, reinforcing the relationship between stress and pain with resulting adverse efTects on the immune system. For exampK', correlation between stress and delayed wound healing as a result of a prolonged inflammatory stare was discussed in a case study on stress response in a paraplegic patient with pressure ulcers (Jones, 2003). Much bas also been written about tbe effects of tbe anticipation of pain, especially unrelieved pain in patients who has already experienced a painflil episode (Mangwe