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292 HOLISTIC MANAGEMENT OF PAIN
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The importance of this model relates to the interconnectedness
of the component parts that produce the neurosignature.
Practitioners need to interpret this alongside patients, because it is
individual and helps to account for why people have dierent pain
experiences. It is also of value because it can be used to decipher and
explain persistent pain, which can be a major component of living
with a leg ulcer. As this model has developed it can be described as
not just biopsychosocial but also as having an existential component:
the meaning that is given to the pain experience (Dezutter
etal.2015).
Today’s scientic research is taking a step further to determine
pain. Lyman (2021) writes that ‘pain is not detected by the brain, it is
created by it’ and that it is ‘a conscious translation of our unconscious
brain’s decision that the body is in danger’ (Lyman 2021). In
understanding what this means for our leg ulcer patients it is helpful
to look at what some of these inuences are in more detail. As Lyman
(2021) also writes, ‘Pain is a decision made by the brain– the vast
majority of which is outside our conscious control – to tell our
conscious mind that we are in danger.’
CAUSES OFPAIN
The World Union of Wound Healing Societies (2004) provides useful
descriptions that help establish the broad term of wound- related pain
to be broken down into a number of causes that should assist a
clinician in their joint exploration of pain with the patient. These are
described as follows:
Background pain from the underlying aetiology of the leg ulcer-
ation and the wound itself, such as local inammation
or oedema.
Pain incidents such as daily activity and walking.
Procedural or operative pain from the wound treatment itself or
the dressing change.
Patients are unlikely to be experiencing just one kind of pain and
so it is important that dierent types are distinguished.
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TYPES OFPAIN
Nociceptive pain is caused by the stimulation of peripheral nerve
bres, which sense and respond to aected or damaged areas of the
body. The sodium channels within the nerves can act as a volume to
the pain intensity (Lyman2021). Nociceptive pain may be dened as
‘an appropriate physiological response to a painful stimulus. It may
involve acute or chronic inammation’ (WUWHS2004). Typically
this is short- lived (acute) when due to infrequent trauma or procedure,
or it can be cyclic in nature if it becomes a regular occurrence
(Acton 2007). The sensations experienced are typically localised,
with constant aching and throbbing (Table 6.2). Where the
innervation becomes persistent there is an overstimulation of
nociceptors; the prolonged inammatory response may cause
heightened sensitivity in both the wound (primary hyperalgesia) and
the surrounding skin (secondary hyperalgesia) (WUWHS2004).
Neuropathic pain develops due to damage to the somatosensory
system (NICE2022), thereby occurring when there has been either
peripheral or central nervous system dysfunction or damage. The
eect is to elicit altered sensations, which are often unpleasant.
Descriptors of neuropathic pain include burning, tingling, pins and
needles and electrical shocks located in and through the aected
area. Related sensitivity to often non- painful stimuli such as light
touch, pressure or changes in temperature can provoke intense pain,
which can become persistent. This enhanced sensitivity is known as
hyperalgesia or allodynia and is dependent on which nerve bres are
aected (Wulf and Baron2002; WUWHS2004; Sandkühler2009).
Neuropathic pain can be dicult to treat, so requires recognition and
management that includes specic pharmacological preparations.
Nociceptive and neuropathic pain may manifest in distinct ways
with patients using dierent words or descriptors to describe their
experience (Box6.1). Finding words that resonate with the individual
will aid in the communication and evaluation of any strategy.
However, on occasions nociceptive and neuropathic pain may
also be dicult to distinguish from one another as symptoms overlap
and become similar (Jenkins 2020b). This, alongside their joint
presentation in the same person, makes for a complex pain prole.
When nociceptive pain is inadequately managed, persistent pain
may develop with both nociceptive and neuropathic properties
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Box 6.1 Pain Descriptors That May Help
Communicate theLived Experience
Nociceptive Neuropathic
Throbbing
Sharp
Dull
Sore
Aching
Source: Adapted from NICE (2022) and EWMA (2002).
(Taverner et al. 2014), although non- healing wounds seem to be
associated with neuropathic pain. Hypersensitivity is poorly
understood by clinicians and leads to a ‘lack of belief in the extent of
the patient’s pain’ (Hopkins and Worboys2005). Understanding the
patient’s lived experience of pain, inuenced by variables such as
wound care procedures, is critical if we are to determine an eective
treatment plan. This inuences the clinician’s approach to
compression therapy and the management plan being suggested (see
Chapter8).
Pain has been described as acute and shortpersistent if of over seven weeks’ duration (EWMA2002). However,
there has been more recent debate as to the use of the term ‘chronic’
and how to dene where acute pain ends and long- term pain begins.
It has been suggested that another name for chronic pain is persistent
pain, with certain characteristics being presented that can be helpful
for the practitioner in understanding their patient’s journey. The
debate continues (Nicholas etal.2019). Denitions of persistent pain
are debated (Upton and Upton 2015; Nicholas etal. 2019), but the
characteristics relate to the following:
Shooting
Burning
Stabbing
Tingling
Numb
Prickling
Itchy
lived or chronic and
Pain persisting over seven weeks (Wulf and Baron2002) and over
longer periods. This will be the experience of many leg
ulcer patients.
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The specied duration of ‘long period’ is classied as being over
three months (Treede etal.2015). A high percentage of leg ulcer
patients do not have their wounds healed in under 12
that the potential for long- term pain complexities is great.
Pain that exists beyond the period of expected healing (Treede
et al. 2015). For venous leg ulcer management this will be
12 weeks, but it is harder to determine for other aetiologies.
Pain that may continue post healing. This is an important
reminder for clinicians as patients may be left with residual sensations or even pain after healing; healing the wound is only one
of the desirable outcomes for managing patients with lower limb
wounds and conditions.
‘Pain that stopped being a symptom and has become the disease’
(Lyman2021; Wulf and Baron2002).
weeks, so
PAIN CYCLES: NEVER- ENDING PAIN
Pain can be disruptive, life altering and self- perpetuating. Cycles of
pain relate to the never- ending narrative of living with pain. Energy,
sleep, mood and activity are all interrelated and if a patient is
struggling in one area it will have an impact on the others. Upton and
Andrews (2013) found a signicant correlation between wound pain
and sleep disruption. If a patient is anxious, fearful or depressed, this
will aect their sleep. Lack of sleep and the necessity of having to
cope with pain decrease energy and make it dicult to be active. Pain
together with lack of exercise and movement increases pain,
particularly where ankle range of motion is aected (Davies
etal.2007). This in turn aects mood (Upton2014).
Pain cycles are self- perpetuating and in wound care include
those that relate to wound care procedures and specically dressing
changes. Upton and Upton (2015) talk about pain at dressing change,
which can easily become a perpetual cycle of pain leading to more
dressing. The cycle goes like this. There is pain at dressing change,
which leads to stress and related anticipatory pain when dressing
time approaches. The patient may then adopt avoidance behaviour,
which can cause delayed wound healing, exacerbating pain and
initiating the need for more dressings, which are now perceived as
being painful. As patients become more anxious or stressed in
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anticipation of pain, they will also rate their pain higher (Colloca and
Beneddetti2007). Within this cycle it is easy to see how a patient may
be labelled nonin. Perhaps less obvious is the role that nurses can play to alleviate or
even negate the discomfort experienced.
concordant as they seek to alleviate the cycle they are
IMPACT OFPAIN ONPEOPLE’S LIVES
The experience of pain is individual, but numerous studies have
highlighted commonly encountered factors that can potentiate pain.
It is important to understand and identify what is likely to increase
pain so that there can be mediation and appropriate care can be given
and planned for. Table6.2 identies some of these considerations.
Stress, anxiety and fear are closely linked and well documented
as being inuencers and predictors of increased pain that delays
healing. The impact on sleep is a common feature of quality- of- life
studies (Green etal.2017; Hellström etal.2016; Taverner etal.2014;
Upton and Andrews2013). Green etal. (2017) found that ‘the lack of
sleep seemed to accentuate the debilitating nature of the condition
and made day- to- day functioning more challenging’.
CAUSES OFPAIN
The literature is inconclusive about whether the severity of the pain
is predicted by the wound aetiology. Experience can tell us it can be,
but clinicians need to be mindful not to be aected by the experiences
of others. It remains critical that clinicians come to the assessment
with an open mind and ready to listen to the patient’s experience.
The myth that pervaded for many years was that arterial ulcers are
more painful than venous and so clinicians were already making a
value judgement on how much pain a patient was likely to be in. It is
now recognised that this is erroneous.
Briggs et al. (2007) found that severity of the pain cannot be
predicted by the wound type, size or duration of the leg ulcer.
Hellström etal. (2016), in their study of elderly patients, found that
pain intensity varied with wound type, those with multiple ulceration
of dierent diagnoses scoring the highest (Table6.3). Of note is that
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TABLE6.3
Leg ulcer type Findings Implications
Venous leg
ulceration
Arterial leg
ulceration
Mixed venous/
arterial leg
ulceration
Source: Adapted from Hellström etal. (2016).
Leg ulcer types.
50% no pain
31% scored 5–10
27% no pain
54% scored 5–10
39% no pain
47% scored 5–10
A signicant proportion experienced
severe pain. When 50% can
experience no or resolved pain,
the patient in pain can be ignored
or disbelieved.
There remain some patients who
experience nil or resolved pain.
However, a signicant number
experience severe pain.
It is of note that despite arterial
disease, a signicant number of
patients experience nil or resolved
pain. However, nearly 50%
experience severe pain.
over 70% of patients with bilateral ulceration were identied as
having signicant pain. ‘Higher pain intensity was associated with
increasing odds of having sleep disturbances’ and increased rapidly,
with a score of over 4 on a numerical rating scale. Hellström etal.
(2016) also found a number of patients who reported no pain and still
had signicant sleep disturbances, thus this remains a critical
question in assessment. While a number of patients said they had no
pain associated with their ulceration, it remains signicant that a
high proportion had scores of 5–10in severity; this may be related to
a wound, infection, erosions or unmanaged swelling. This group
needs to feel heard and have their experiences explored if pain is to
be successfully managed.
Certain conditions may predispose to articulations of particularly
painful experiences. This includes inammatory processes
manifesting as part of the underlying pathology. Thus, sickle cell
disease, vasculitis including pyoderma gangrenosum, and atrophie
blanche may all experientially be found as extremely painful. See
Chapter 3 on unusual aetiologies and Chapter 8 on compression
therapy and its role in reducing inammation.
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PAIN MANAGEMENT SOLUTIONS: ASSESSMENT
Managing pain can be a signicant challenge for those with leg
ulceration and the clinicians caring for that person. Management is
rooted in intelligent assessments to understand the patient’s story in
relation to their current circumstances and presenting symptoms.
WUWHS (2004) suggests a layered approach in assessing pain at woundrelated procedures consisting of initial, ongoing and review assessments.
This guidance is a helpful way of approaching the whole impact
of pain in a more fundamental way. Wound care procedures are just
one aspect of living with a leg ulcer and if pain management is to be
meaningful, the assessment needs to encompass all stages of the
experience for that patient. WUWHS (2004) talks about assessments
needing to be carried out by experienced practitioners with good
listening skills. Factors such as feelings, perceptions and beliefs,
along with the meaning and impact of pain for that person and the
surrounding family, require exploration. The need for establishing a
conversation with the patient is paramount to acknowledging the
patient’s experience (Jenkins2020b; Ballantyne and Sullivan2015).
Patients need to be able to tell their story, some of which will be about
presenting issues, and to feel that they are being listened to in a nonjudgmental but informed way. See Box6.2.
Box 6.2 Asking Questions toUnderstand
Remember: Assess and document regularly!
Be prepared to listen.
Do not form preconceived ideas.
✓ The pain history
✓ Pain trends
✓ Where is the pain?
✓ What is it like?
✓ What makes it worse?
✓ What makes it better?
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Patients’ Pain
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Comprehension and the ability to communicate thoughts and
beliefs underpin the use of any assessment tool. Where there are
language barriers it is important that translation solutions are sought.
In situations where cognitive dierences exist or other forms of
communication are required, an acknowledgement of this need
alongside appropriate and alternative ways of communicating will be
required. Equally practitioners need to be aware that patients may be
reticent in disclosing information. Green etal. (2017) found that patients
did not always disclose their issues with clinicians during consultation,
even when these had been identied as important; this underlines the
need for clinicians to create a safe space where the disclosure of sensitive
or personal information can be heard and holistic care can be provided.
There are numerous assessment tools available to the practitioner
(Feldt 2000; Hockenberry et al. 2005; Woo et al. 2008), although
Leren etal. (2020) found that they were used inconsistently. Some of
these tools are more age specic or helpful where cognitive ability
needs to be addressed. Others are very comprehensive, but can be
lengthy and time consuming to complete in the clinical eld.
Organisations may also have their own guidance about which tools
should be used for a cohort of patients. What is important is that the
practitioner becomes cognisant with the tool they are using and that
there is consistency with other clinicians to monitor and evaluate
progress, including any interventions within ongoing care. Where
tools are used it is helpful to have them embedded within a narrative
that explores the wider context of the lived experience.
Validated quality-
of- life assessment frameworks such as the
Quality- of- Life Scale or the Sickness Impact Prole provide much
more detailed information. They may be less easy to use in clinical
settings where transient sta are not familiar with the tool, or where
time has not been allowed for a more detailed exploration of the
patient narrative. Green etal. (2017) have developed an assessment
template that goes beyond physical considerations to consider
quality- of- life factors and concerns.
Validated assessment scales are of value at all stages of leg ulcer
management, whether as part of an initial assessment or for ongoing
monitoring (Table6.4), and are recommended for review at dressing
changes. They are not mutually exclusive and when used with other
quality- of- life frameworks can be the source of rich information to
inform and evaluate care in an intelligent and comprehensive way.
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TABLE6.4
Type of
assessment tool Description Comments
Visual scales Visual analogue
Numerical Numerical rating
Verbal Visual rating scale (VRS).
Assessment scales.
scale (VAS).
This includes the
Wong-
Baker Faces
scale, which presents
as a range of faces from
happy with ‘no hurt’
through to upset with
‘hurts worse’.
Numerical values are
attached to the faces
with the higher scores
indicating the
worse pain.
scale (NRS).
A numerical value is
placed against the pain
rating (0–10 or 0–100),
so no pain may be rated
as 0 and the worst
possible pain as 10.
Uses a scale of descriptor
words, such as ‘none’,
‘mild’, ‘moderate’
or ‘severe’.
Can be useful for children,
but less so for those with
cognitive impairment
such as those
with dementia.
Simple, replicable and
communicable.
Some people nd it
dicult to engage with
numbers and nd words
or pictures easier.
Some nd the variation in
pain during the day
dicult to score,
especially if it is episodic
neuropathic pain.
Simple, replicable and
communicable.
Can be used on a
standalone basis or with
other scales.
Simple, replicable and
communicable.
Source: Adapted from WUWHS (2004).
Pain diaries written by the patient are of value to explore the pattern
and nature of ‘why I have pain’ (EWMA2002; Mudge and Orsted2010;
Upton2014). These may be helpful where patients are interested in
and able to write a narrative, albeit they do not suit everyone.
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Where patients have multiple causes and experiences of pain,
these scales oer limited information. Leg ulcer patients may present
with any number of variables that are contributing to their pain
status, but without a narrative or surrounding detail they can oer
only a snapshot of a trend towards either having pain or being
without pain. Recognising this and ensuring the patient’s experience
is heard and solutions oered are vital. Enabling the patient to
describe their pain, ‘giving them descriptive words to choose’
(Acton2007), can help in conversation and understanding.
The clinical team needs to provide a consistent approach to the
exploration so that the outcome of the clinical or pharmacological
interventions can be observed. Box6.3 gives some guidance on what
areas can be explored with the patient. The practitioner also needs to
be aware of what will be the preferred or best way of gaining insight
and this will depend on the choice of tool for that patient as well as
how the conversation is framed.
Those who have learning disabilities or are cognitively impaired,
such as those with a form of dementia, will need to have their pain
described or interpreted in dierent ways. The Wongscale may not be helpful for those with cognitive impairment (Upton
and Upton2015). Alternative tools may enable a clinician to explore
pain through the person’s own descriptors or the use of non- verbal
cues (Box 6.4). These scenarios can be better explored with carers
who know the patient well and can provide new evidence or
comparators. Body language is always an important indicator of
Baker Faces
Box 6.3 Understanding thePain Experience
When and for how long.
Type of pain descriptors: nociceptive or neuropathic or a mix.
Severity using a visual or numeric tool.
Impact and consequences on sleep and daily life.
Factors that exacerbate or reduce the pain, coping strategies.
Relief rating with analgesia or other interventions.
Adverse eects of current or future treatment.
Source: Adapted from Acton (2007).
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