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Box 6.4 Alternative Tools forExploring Pain
When your patient has learning diculties or is cognitively
impaired, use an established pain tool to document the pain
assessment. This will include the following:
The perception of pain from a main carer
Impact on breathing
Vocalisation or changes
Facial expression
Body language
Consolability
Source: Adapted from International Association for the Study of Pain
(2019).
whether someone is in pain and so non- verbal cues must not be
ignored (Feldt2000).
Exploring the pain experience within children is another area
that requires special mention. Carter and Simons (2014), in their
comprehensive book focusing on the stories of children’s pain,
thoughtfully and comprehensively look at neonatal pain in through to
adolescence. In their introduction they write that ‘through attending
to stories...we have a chance to start to understand what is important
to the children, young people, and families for whom we care. If we
ignore their stories, we are ignoring who they are as well as what we
can do for and with them.’ Stories are an important part of our
assessment, but also our ongoing review and management. Children
will have dierent experiences and diverse ways of articulating and
viewing the world. Understanding, cognition and stage of development
will all play a part. What is important is that clinicians who care for
young people with leg wounds are aware that articulation of pain and
suering may be dierent and that management modalities will need
to take account of the childhood experience, level of understanding
and expression.
Interpretation of patient narratives must also be done with
understanding and without prejudice. Cultural characteristics are
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often thought to inuence the reporting of pain, but clinicians need
to be greatly aware of biases, including unconscious ones, that are
present in how people are managed, especially when the patient
belongs to a dierent racial or ethnic group. There is an increasing
awareness of health inequalities and disparity in treatments due to
race and socioeconomic group, with an adverse association between
non-
white patients and the treatment of chronic pain (Morales and
Yong2021). Equality of access may also be aected by age. Leren
etal. (2020) found that increasing age did report a reduction in pain
intensity score, but no dierence between genders or ulcer durations;
however, Taverner etal. (2014) found that older adults are less likely
to report pain due to stoicism and less likely to receive a pain assessment and adequate analgesia.
MANAGING PAIN
For management to be eective, it needs to be linked to what is
triggering or exacerbating the pain being experienced and is a
particular concern at dressing change. However, this exploration of
pain and its impact demonstrates that pain management in lower
limb wounds is far more than careful removal of a dressing. This may
be underlying disease pathology, local wound factors such as infection
(Mudge and Orsted2010) or excess exudate, wound care procedures
or psychological and social factors. Existing co- morbidities may have
a negative impact contributing to either background or principal
pain, further complicating the pain prole. At times the complexity
of pain management can seem immense for both patient and
practitioner, particularly where persistent pain exists. Despite this, it
is important to acknowledge the power that practitioners have to
make a positive dierence in the lives of their patients. See Table6.5
for a summary of the key actions to consider. Do we understand and
acknowledge the potency we hold as clinicians to make a positive
dierence to our patients?
In determining the management of pain, WUWHS (2004) writes
that treatment of the underlying cause and associated pathologies is
the most important consideration in the management of wound
pain: ‘Treat, where possible, the underlying aetiology of the wound
or associated pathologies.’ Certainly, the correct management for the
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TABLE6.5 Key messages that will make adierence topatients.
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Domain Practice
Competent
and skilled
practitioners
Assessment Make sure that your patient feels heard and validated.
Management Oer explanation to inform and discuss.
Develop the necessary knowledge and skills related to lower
limb management to become competent practitioners.
Use your skills and knowledge in an informed way to
manage expectations, bring condence to the patient
and deliver therapeutic care.
Early intervention to commence therapeutic management.
Use language that is positive, thoughtful and encouraging.
Ensure that their pain is not dismissed.
Be certain that you acknowledge and understand their
pain experience.
Recognise and respond to non-
indicators of pain.
Make sure that assessment is without prejudice or bias.
Use validated tools.
Treat the cause.
Refer on for unusual aetiologies and vascular implications.
Medication management. Liaise with the medical
prescriber and consider:
Is the medication eective?
Is it being taken appropriately?
Are there medication side eects such as hyperalgesia
that are negating the therapeutic intervention?
Wet wounds, frequent infection and unmanaged oedema
all add to the pain experience, so:
Manage exudate. Ensure eective limb oedema manage-
ment. Skin care protects surrounding skin and promotes
skin integrity. Apply appropriate absorbent dressings.
Manage infection episodes. Know the infection
continuum and when antibiotics are required. Early
detection will avoid pain amplication.
Manage oedema. Oedema can cause ‘heavy’ legs with
dull, aching and persistent pain. Apply eective and
therapeutic regimens that are comfortable and well
tolerated.
Refer on in a timely manner for complexities that require
specialist intervention. This will help to avoid further
complexities occurring and will include:
Pain team.
Tissue viability team.
Foot care team.
Psychological support.
verbal as well as verbal
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TABLE6.5 (Continued)
Domain Practice
Dressing
change
Managing
expectations
Listen to the patient’s fears or experience related to
previous dressing changes.
Is analgesia required at the outset? Are there any triggers?
Engaging the patient in conversation will help to distract
them away from focusing on pain. Focus them on
breathing during the procedure.
Give control to the patient, allowing self-
dressing and adjusting treatment to reduce pain. Oer
‘time out’ as required.
Consider cleaning and debriding techniques and what
makes the experience painful. Does exposure to air or
washing the leg cause more pain. Could other
methods/preparations be used?
Skin care: ensure that skin conditions like eczema and
fungal infections, which cause irritation and pain, are
being eectively managed.
Consider the dressing: does this increase pain? If so,
consider other dressings that minimise trauma such as
those that are non-
time to manage exudate thereby avoiding frequent
dressings, or have a gentler action on the wound.
Consider the compression:
Is the compression eective?
Know the art as well as the science of compression
bandaging.
Have compression garments been correctly tted to the
patient? Are they comfortable?
The person giving the treatment inuences the pain
experience for the patient. Aim for therapeutic
relationships that are based on trust.
Use constructive words and phrases that are positive and
encouraging.
Expectation inuences perception, so:
Be aware of and talk about the patient’s
expectations of care.
Be mindful that professional expectations may not be
the same as the patient’s.
Oer transparency in care and be prepared to identify
and reconcile any dierences in expectations.
adherent, have an optimum wear
removal of
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(Continued)
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TABLE6.5
Domain Practice
Empowerment Empower through listening and acting on patient
Coping
strategies
Staying active Discuss and encourage mobility and activity.
(Continued)
experience.
Enhance patient skills by linking their experience to
clinical knowledge.
Encourage selfOer peer support including Leg Club frameworks.
Support the patient to develop their own strategies.
Promote positive conversations.
Signpost and/or refer for specialist support where needed:
Clinical psychologists.
Psychotherapies: counselling such as talking therapies
and mindfulness techniques.
Patient activation schemes.
Life coaching.
Refer to occupational therapy for functional aids and
adaptations.
Enhance ankle range of motion– teach TheraBand
exercises.
Encourage occasions for social interaction. This could be
related to a craft- making activity.
Consider social prescribing opportunities.
Signpost to activity classes: swimming, gym, dance, walking.
belief and ecacy.
presenting aetiology is an essential part of pain management. Patients
with chronic venous insuciency will require therapeutic strong
compression therapy. If ischaemia is present, vascular intervention
will be necessary to restore the blood supply. Where presentation of
the ulcer(s) is unusual to the clinician, referral to a specialism such as
dermatology will be required to diagnose and commence systemic
therapy or some other form of intervention (see Chapter4).
Analgesia
Analgesia forms a vital and foundational part of managing pain. The
practitioner needs to understand the analgesic options and be able to
work with the patient and the medical prescribing team to facilitate
the best possible regimen for the patient. Decisions on what will be
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benecial are not always straightforward and considerations need to
include contraindications, allergies, previous reactions as well as
drug interactions, existing medication, and drug dependency history.
The World Health Organization analgesic ladder, developed in 1986,
is often used to help rationalise decision-
making. It is important to
note that this often- referenced model has been critiqued and suggestions for modications made (Anekar etal.2023). Co- analgesics that
work alongside these medications include anticonvulsants and antidepressants that target neuropathic pain. Knowledge of the type of
pain, and where possible what is either causing or exacerbating it,
will assist in this decision- making process. Where people are already
on strong analgesics for other pathologies or lifestyle choices, medication will need to be carefully considered, as pain tolerance and
thresholds will already be aected. If pain is mostly related to specic
events, such as wound care procedures, analgesic options should specically target those occasions, but both background and incident
pain must be well controlled if pain intensity is to be minimised during dressing changes (WUWHS2004).
The use of opioids within leg ulcer management requires
thoughtful application. Opioids work well in acute pain scenarios,
but they can be addictive (Jenkins 2020a). Where persistent pain
exists the use of opioids is likely to be problematic with little benet
(Ballantyne and Sullivan2015; Jenkins2020a). Long- term use can
contribute to the inammatory eect, with the potential of adding to
the pain experienced. The tendency to increase the dose of the opioid
is likely to lead to a state of hyperalgesia that, rather than controlling
the pain, instead increases perception and sensitivity to pain
(Lyman2021). Dependency on the opioid may also lead to bouts of
drowsiness and inactivity, which are opposite to the management
need to get people moving and active. Dependency may also be problematic as patients encounter withdrawal symptoms when they step
down from taking the opioid.
Patients have a choice in taking analgesia. This can be a source of
frustration to clinicians if advice has been given to take medication to
alleviate discomfort around a specic regimen, such as wound care
procedures, and this is ignored. Patients may be labelled as nonconcordant in these instances (see Chapter7 for exploration of this
topic). However, it is important to remember that choice resides with
the patient, who may have valid reasons for or beliefs about not taking the medication. Perhaps this is also a timely place to remember
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that ‘in the case of persistent pain, the most eective treatments we
often have are non- pharmacological’ (Lyman2021). Alleviating and
managing pain do not solely reside in the pharmacological, with
other solutions increasingly being recognised and resourced. The clinician plays an important frontsolutions.
line role in these options and
Compression Therapy
Compression therapy is the treatment for venous insuciency and
management of lower limb oedema, where there are no vascular
contraindications (see Chapter8). Tolerance of compression therapy
is multifactorial, but discomfort or increase in pain may be
experienced. The participants in Taverner etal.’s (2014) study describe
how compression therapy or exercise worsened their pain. The
patients developed coping strategies to manage this. Unfortunately,
the reason for the increased pain from compression therapy was not
explored, but it tells us that exploration and identifying why and
where it is painful are paramount. People expect to have pain with an
injury and that this pain will diminish with eective treatment.
When the wound is not healing but treatment carries on, the presence
of continual pain at this stage is described as ‘pain without purpose’
because a benet, in this case the healing, was not being seen; one
can surmise that the compression therapy was not provided at a
therapeutic level and thus was ineective, creating a non- healing
wound. This allowed the participants to enter a ‘chronic pain state’
that was associated with insomnia, depression, pain at night, loss of
mobility and suicidal ideation. Compression therapy may be a
dicult treatment to tolerate and thus it is incumbent on the
practitioner to increase their own knowledge and skills to enable the
patient to have this successful treatment (Hopkins and Worboys2005).
Unfortunately, the skill of the practitioner is rarely mentioned in
the literature when discussing the issue of pain and discomfort with
compression therapy. Compression therapy applied at an
inappropriately high level is noted and identied as a risk for pain
and non- concordance (Boxall et al. 2019), but delivering an
inadequate dosage of compression will also lead to increased pain
and exudate because the venous disease and inammation are not
being treated; this leads to a lack of trust in treatment ecacy and
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thus a lack of adherence to a regime that is not benecial to the
patient. Nevertheless, correctly tting and skilled compression
therapy, including appropriate compression garments, leads to a
reduction in pain and improvement in quality of life (Berszakiewicz
etal.2021).
Psychosocial Management
Distraction
Distraction is a potent reliever of pain as it can refocus the person’s
attention away from the pain experience. Preoccupation with pain
accompanied by low moods and anxiety can draw the patient into a
world dominated by pain. A cohort of patients with lower limb
wounds and oedema will be housebound and/or have sedentary lifestyles. Social interaction may be limited, with emotional moods being
negatively impacted. Bringing attention to pain even by introducing
words may increase the pain experienced (Hall and Stride1954).
Distraction oers a way of focusing attention away from
potentially harmful stimuli elsewhere. Opioids are naturally
produced in the body to decrease pain and in distraction opioids are
produced to enable the blocking of nociceptive signals. Increasingly
there is evidence of virtual reality being used as a distraction device
in a variety of clinical settings for the purpose of managing pain
(Indovina etal.2018). Homan etal. (2011) found reductions in pain
when used with burns patients.
Expectation
Pain can be manipulated through beliefs and expectations.
Expectation inuences perception and this has a physiological
dimension; if pain relief is expected the body will produce opioids
including endorphins to manage the pain. Studies looking at the
placebo eect have clearly demonstrated the power of perception
(Wager et al. 2007). The ‘nocebo’ eect occurs when negative
expectations are transferred to the patient, causing this negativity to
become the patient’s perception. Alternatively, positive and
constructive words and ideas will have a positive eect. See Box6.5
for examples. Setting realistic patient- centred goals will also be
benecial and can link into a sense of progress.
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Box 6.5 The Nocebo Effect
The nocebo eect can be triggered by phrases such as:
‘You’re a high- risk patient.’
‘You have a chronic condition.’
‘You have chronic pain.’
‘This will hurt.’
‘You are non- compliant.’
These place emphasis on the side eects or negative impact of
treatment as opposed to the positive.
In contrast, positive words and concepts, including use of
metaphors, help to rewire the brain.
They encourage feelings of safety, oer positive reinforcement,
reduce a sense of danger and provide hope. This is particularly of
relevance where therapies may be new to the patient. The clinician should show condant compassion.
Source: Adapted from Lyman (2021).
Empowerment
Helplessness and feelings of being unseen and powerlessness have
negative impacts on the pain experience (Woo etal.2008; Rosenburg
etal.2022). Rosenburg etal. (2022) write that ‘a patient who is cared
for, is one who is noticed’; the patient becomes seen. Learned
helplessness, where people have learnt to expect that they will not
succeed, leads to powerlessness in decision- making. Such feelings
may result in emotional states such as depression and these negative
emotions combined with feeling threatened can give rise to
expectations of pain and suering. Conversely, empowerment and
having a sense of control should have a positive impact. Reframing
beliefs and encouraging choices contributing to leading a healthy
lifestyle, with an emphasis on sleep, socialising and healthy diets,
will have benecial eects. Dezutter et al. (2015) when looking at
meaning in patient proles found that ‘the ability to nd meaning
and purpose despite physical challenges can change the lens through
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which the individual views the destabilising events of his/her life’, so
that the threat of chronic pain is replaced with a perspective of
challenge.
Staying active is vital for patients with lower limb ulceration and
oedema. Avoiding activity often begins with reacting to and
anticipating pain rather than seeking choices to help manage it.
Activity will not only be a technique for distraction, inuencing
expectations and feelings of empowerment, but will also be an
essential element in improving the physiological elements of
underlying pathologies. Increasing ankle range of motion will have a
positive impact on reducing pain, for instance (Chapter4).
In determining psychosocial support for patients, it is helpful to
be reective and consider what information would be helpful (see
Box6.6). Being reective on clinician interaction will also assist in
developing a therapeutic relationship that aims to oer a safe place
for further discussion and partnership working.
Box 6.6 Questions toPonder
Is my patient housebound or restricted in lifestyle?
How much social interaction do they have?
What activities are they involved in?
Is my patient inclined towards low moods?
In what ways do I hinder my patient when they are made to
feel non- compliant?
How do I engage with my patient during visits, especially dur-
ing dressing changes?
What words do I use with my patient? Are they positive and
arming?
How do I introduce therapies and treatments?
Are there opportunities to introduce distraction?
Are there any activities that can be introduced or promoted?
Do I have a therapeutic relationship with my patient built on
trust? This will include being a competent practitioner with
the necessary knowledge and skills.
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