Quantifying the Pain

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August 2004

By Karen Wientjes Albaugh, PT, MPH, CWS

A thorough wound examination typically includes assessment of present and past medical history, measurement of the wound size, and a description of the wound bed composition. A check of the patient's vascular supply, sensation, and range of motion and other special tests are likely to follow. A formal pain assessment is often included at initial examination and reevaluation. "How would you rate your pain on a scale of 0-10, with zero meaning no pain and 10 meaning the worst imaginable pain?" Perhaps the clinician has even structured a goal to decrease the reported pain score over the next few weeks. Does the assessment of pain stop there?

Increasingly, health care providers are asked to delve deeper into the multifaceted pain experience. Newly revised JCAHO standards state that patients have a right to appropriate assessment and management of pain. Furthermore, the standards emphasize that pain management must be part of the treatment plan.¹ In addition, the Agency for Healthcare Research and Quality recommends routine assessment of pain, whereby health care providers are not to assume absence of pain in patients who are unable to express it.² These standards highlight the need to press further for a qualitative value to a reported "8 out of 10" pain score. To appropriately manage wound pain, we must attempt to identify the source of the pain, better define when the it occurs, and choose from an array of relief strategies.

PAIN AS AN INDICATOR
Foremost, it is important to recognize the function of pain as a natural alarm for injury and/or tissue compromise. Without this indicator, repeated trauma is apt to lead to further tissue destruction. This is often the case with patients who have diabetes. Insensate feet do not transmit pain signals to alert the patient that they have stepped on a sharp object. In an average day, we typically shift and change position to relieve the sensation of increased pressure. Without the protective function of pain, pressure is liable to progress to ischemia and ultimately ulceration. In this respect, pain is not necessarily "bad." To be devoid of the pain response could be limb or life threatening.

There are many potential sources of wound pain. Recent findings from an international study conducted by the European Wound Management Association revealed that 63% of patients experience pain at the time of dressing change.³ An additional 30% experienced pain during routine wound cleansing. Adherent or dried out dressings are most likely to cause pain and trauma. Krasner describes this type of wound pain as acute cyclic, occurring at regular intervals.⁴ The predictable nature and the expectation of pain add a heightened psychological dimension to the physical experience. As clinicians, it is important for us to keep in mind that this daily or twice daily experience exposes the patient to a significant amount of pain.

Various wound etiologies will predispose patients to wound pain. Although pain is uncommon in the diabetic foot, its presence may herald the onset of limb-threatening complications and, therefore, should trigger concern. Diabetic wound pain appears to be related to neuropathy, deep infection, Charcot foot changes, and/or critical ischemia.⁵ Neuropathic pain has been described as burning, stinging, stabbing, or shooting, while Charcot changes produced sensations of throbbing or soreness. The onset of pain with deep infection is often subtle; therefore, it is imperative to look for other clinical signs of infection. Ischemic pain is often exhibited with exertion or at rest in extreme cases. Diabetic foot pain has been further linked to such decreases in overall quality of life as insomnia and loss of mobility.⁶

Historically, venous ulcers have been thought of as nonpainful, especially when compared to arterial insufficient ulcers. However, increasing research suggests that as many as 60% to 70% of patients with venous ulcers experience pain or extreme ulcer pain.⁷ The source of pain for these patients includes: edema and varicose veins, lipodermatosclerosis, wound infection, cellulites, acute and contact dermatitis, and atrophie blanche.⁷ Pain is often reported as a dull aching or heaviness sensation occurring in both the wound bed and the involved extremity. Fortunately, this type of pain can often be mitigated by addressing the underlying cause (ie, providing support garments or relieving dermatitis).

Patients with pressure ulcers also present with several underlying sources of wound pain. These include ischemia due to pressure, immobility, nerve damage, and irritation and/or deep infection.⁸ Several studies suggest prolonged inflammatory response creates a combination of hyperalgesia and allodynia, thus perpetuating the pain cycle.⁹ Proper identification of the source of wound pain will help guide pain management intervention. For example, Dallam and colleagues found the procurement of support surfaces for pressure reduction significantly reduced pain in patients with pressure ulcers.¹⁰

PROPER ASSESSMENT OF PAIN
Objective measurement is often difficult when the data is so truly subjective and multidimensional. Collection of both quantitative and qualitative information is necessary to accurately measure wound pain. The Visual Analogue Scale (VAS) and the Numerical Rating Scale (NRS) offer reliable and valid quantitative information related to the intensity of the pain. The Short Form McGill Pain Questionnaire (SF-MPQ) uses descriptors that appear to capture the complexity of quality changes in ulcer pain.¹¹

In addition, it is critical to be aware of nonverbal signs of pain, especially in those patients who are unable to express pain verbally. Behavioral signs of pain include crying, facial grimacing, clenched jaw, restless legs, or drawing away of the extremity. Nonverbal behavioral measurement scales such as the FLACC scale have been found to correlate with the objective pain scale.¹²

Recognizing these underlying and predisposing factors in wound pain demands that the provider seek mitigation strategies appropriate for each individual. Dressing selection is a paramount consideration since wound redressing is the most frequently reported time of wound pain. Moist wound dressings prevent adherence and trauma to the wound bed. Newer dressing technologies-"atraumatics" such as soft silicone, hydrocellular foams-create an optimal environment for wound healing while significantly reducing complaints of pain or trauma with dressing change. When possible, it is also recommended to consider a dressing that can be changed less frequently, thus decreasing the cycle of pain associated with dressing change.

Strategies specific to wound etiology include: management of pressure and ischemia via appropriate support surface for the patient with the pressure ulcer, compressive wraps and support garments for the patient with edema and venous ulcers, and analgesics or antibiotics for the patient with neuropathy or infection-related pain.

Pharmacologic approaches typically begin with the use of NSAIDs, with or without the use of local or topical anesthetics. For example, this may be especially helpful 30 minutes prior to a debridement procedure or a complex dressing change. Advancement to a mild opioid or a more potent opioid analgesic is at the discretion of the physician.

Inclusive of both the pharmacologic and nonpharmacologic approaches is the need for a patient-centered approach. Because of the strong psychological component to the pain experience, it is important to recognize fear and lack of control as factors precipitating heightened pain. Involving the patient in the process by asking them to qualify and quantify their pain is the first step. Redirecting them to focus on what relieves the pain is the next. Allowing the patient to participate in the dressing change or planning process can empower the individual. Perhaps negotiating a "time out" between patient and provider is enough to give the patient a sense of control over the process.

Mind-body techniques have provided additional, nonpharmacologic strategies to ease pain. Instructing the patient in diaphragmatic breathing can not only divert preoccupation with the procedure, but also promote tranquility. Use of guided imagery-envisioning healing sensations and new cell growth-can also enhance patient participation. These techniques can later be used when the patient experiences pain with a specific activity or while sleeping at night. Advanced research in the field of psychoneuroimmunology is increasingly identifying a link between intention to heal and the impact on lessening the perception of pain. Patients must be encouraged to have a positive attitude toward healing and avoid being consumed by thoughts of pain.¹³

To abolish pain completely would be to eliminate the very protective mechanism that tells us of injury or impending danger. The challenge that providers have in facilitating optimal and comprehensive healing is to appropriately assess the nature of the pain experience in a patient with a wound. Qualifying an "8 out of 10" pain score involves investigation of what type of pain, how often, what exacerbates it, what relieves it, and, most important, what underlying sources may be contributing to the perceived pain. In order for the pain scales to be useful, we must make them meaningful.

Karen Wientjes Albaugh, PT, MPH, CWS, is an instructor at the Physical Therapy Program, Neumann College, Aston, Pa, and clinical coordinator of research and hyperbaric medicine at the Center for Advanced Wound Care in Reading, Pa.

REFERENCES

JCAHO standards. Available at: www.jcaho.org. Accessed July 14, 2004.
Agency for Healthcare Research and Quality. Available at: www.ahrq.gov. Accessed July 14, 2004.
Moffatt CJ, Franks PJ, Hollingworth H. Understanding wound pain and trauma: an international perspective. European Wound Management Association (EWMA) Position Document. 2002:2-7.
Krasner D. The chronic wound pain experience: a conceptual model. Ostomy/Wound Manage. 1995;41:20-25.
Sibbald RG, Armstrong DG, Orsted HL. Pain in diabetic foot ulcers. Ostomy/Wound Manage. 2003;49(4 suppl):24-29.
Ribu L, Wahl A. Living with diabetic foot ulcers: a life of fear, restrictions and pain. Ostomy/Wound Manage. 2004;50:57-67.
Ryan S, Eager C, Sibbald RG. Venous leg ulcer pain. Ostomy/Wound Manage. 2003;49(4 suppl):16-23.
Reddy M, Keast D, Fowler E, Sibbald RG. Pain in pressure ulcers. Ostomy/Wound Manage. 2003;49(4 suppl):30-35.
Popescu A, Salcido R. Wound pain: a challenge for the patient and the wound care specialist. Adv Skin Wound Care. 2004;17:14-22.
Dallam L, Smyth C, Jackson BS, et al. Pressure ulcer pain: assessment and quantification. J Wound Ostomy Continence Nurs. 1995;22:211-218.
Nemeth KA, Harrison MB, Graham ID, Burke S. Understanding venous leg ulcer pain: results of a longitudinal study. Ostomy/Wound Manage. 2004;50:34-46.
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nurs. 1997;23(3):293-297.
Wientjes KA. Mind-body techniques in wound healing. Ostomy/Wound Manage. 2002;48:62-67.

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August 2004