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282 ASSESSMENT OF LEG ULCERATION
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CHAPTER
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6
Holistic Management ofPain
FRAN WORBOYS AND ALISON HOPKINS
ain is a common feature of all types of leg ulceration and lower
P
limb swelling. It is essential that pain as a symptom is understood
and that the complexities of managing this common side eect are
recognised. Pain is more than a physical response to a stimulus and
the clinician needs to understand and manage the associated
psychological features that may exacerbate or diminish the pain
sensations. It is critical that a plan to address these aspects includes
more than analgesia: that the clinician prioritises understanding of
the patient’s lived experience of their pain so that the underlying
features of the pain cycle are included in the treatment plan. The
clinician needs to understand the various theories relating to pain,
the dierent types of pain and factors that have an impact on the pain
experience, which will inform their understanding of the
phenomenon of pain. Myths associated with the pain experience will
be addressed in this chapter.
THE PAIN EXPERIENCE
Pain is a signicant common experience as well as the most
devastating aspect related to living with non- healing wounds (Woo
et al.2008; Price et al. 2008) and, reportedly, the worst aspect of
having a leg ulcer (Briggs etal.2012).
Lower Limb and Leg Ulcer Assessment and Management, First Edition.
Edited by Aby Mitchell, Georgina Ritchie, and Alison Hopkins.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
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285
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The International Association for the Study of Pain (IASP)
denes pain as ‘an unpleasant sensory and emotional experience
associated with, or resembling that associated with, actual or
potential tissue damage’ (Raja etal.2020). This is useful in framing
the nature of pain beyond the physical domain, while raising further
questions about how pain is perceived and in what way it relates to
tissue injury. However, it does not entirely do justice to the complexity
of the pain experience and what it means to live with pain.
There have been numerous qualitative studies that have sought
to nd a deeper understanding of what pain is and how it aects
lives. A number of these have focused on patients living with leg
ulcers and the personal narratives have been able to enhance
understanding of the character of nonlives caught up in an endless pain narrative (Walshe 1995;
Krasner1998; Rosenburg etal.2022).
Pain has been found to dominate the lives of people with leg
ulcers (Green et al.2017), with participants describing the pain as
‘unceasing [in] nature, severity and timing, especially through the
night’. In a study looking at a specic wound dressing on chronic
venous leg ulcer patients, pain was termed as unrelenting with
persistent wound pain uctuating over a 24- hour period, alongside
intermittent bursts of spontaneous pain (Flanagan etal.2006). Key
themes included unpredictability and the challenge of living with
fatigue and activity restrictions.
Leren etal. (2020) in their review conclude that pain is a ‘serious
problem for patients’ and that the issues that subsequently ow from
unresolved pain are signicant and disrupt the lives of the patient
and their families. People with leg ulcers have a signicant risk of
their pain becoming long- standing and persistent, with ‘chronic pain,
insomnia, depression and suicidal ideation being inextricably linked’
(Taverner et al. 2014). Clinicians need to be vigilant from the rst
assessment, as much suering can be reduced if patients’ stories are
listened to and eective management is put into place from the outset.
Clinicians need to be aware of the impact that pain has on their
patients, but there has been concern that practitioners have either
not understood its impact or have placed a low importance on pain
management (EWMA2002; Price etal.2007; Taverner etal.2011).
Arecent Australian study (Frescos2018) assessing pain in chronic
wounds found that although almost all wound care practitioners
healing and the complexity of
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Holistic Management of Pain 287
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participating in the study (n = 1298) asked patients about their
wound pain experience, this reduced to 38% when considering how
many assessed wound pain at every consultation/dressing change.
Pain is a common feature experienced by leg ulcer patients and so its
presence and impact need to be the concern of practitioners.
Pain has been described as being ‘whatever the experiencing
person says it is, existing whenever the experiencing person says it
does’ (McCaery1968), yet if practitioners do not assess, review and
ask the questions, this cannot be ascertained. Pain is also as much
about what the patient does not say (WUWHS2004) as what they do,
and this requires patience, observation, perception and understanding
to facilitate awareness. The recognition of pain and how it is to be
managed form part of the therapeutic partnership and the overall
healing outcomes that practitioners need to have with patients.
THEORIES OFPAIN
Pain Theory Evolution
Numerous theories have sought to explain the physiological processes
behind the pain experience, with the ancient Greeks being the rst to
discover the nervous system. Pain theory in its simplest form
postulated that if there was a linear progression between the point of
trauma or injury and the sensation experienced, it would associate
cause with eect, which could be related to expectation. Skuse (2021)
describes how, in the seventeenth century, Descartes proposed a
theory of pain that articulated the idea that pain was located in
thebrain, with nerves being responsible for stimulating a response.
The rationale arose out of Descartes’ study of phantom limb pain
andthe observation that pain was being experienced from a site that
was no longer part of the body. In his bell- cord theory he identied a
link between an injury and the pain experienced, such that a signal is
sent to the brain and it reacts like the ringing of a bell. This simple
model was suggestive of a pain pathway, but it did little to explain the
complexities and nuances of the pain experience, where the injury
might be the same but the pain narratives between dierent people
in similar situations or the same person in another setting could be
poles apart.
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In the nineteenth century the physiology of the nerves was
revealed, with dierentiation between the cell body, the dendrite and
the axon. The work of individuals such as Charles Bell, Otto Deiters
who saw the nervous system as a railroad (Ehrlich2022), Emil du
Bois-
Reymond and his identication of nerve impulses, C.S.
Sherrington and Jean- Martin Charcot brought a new dimension of
understanding about nerves, the nervous system and the way
impulses travel to the brain. Sherrington discovered that nerves do
not touch one another but communicate by ‘synapse’ across a small
space to the next one, due to chemical and electrical exchanges. This
forms the neural circuitry within the body. Sherrington also identied
the specialised receptors at the end of nerves that detect motor and
sensory activity while linking nerves to muscle activity. These
receptors, known as nociceptors, detect damage and danger by
reacting to noxious stimuli (mechanical, thermal and chemical).
They send electro- chemical impulses along the peripheral sensory
nerve towards the spinal cord and from there to the brain (Molnár
and Brown2010).
In the twentieth century, the study of the nervous system
continued with what is termed modern brain science. The work of
Santiago Ramón y Cajal identied individual cells that are now
known as neurons (Ehrlich2022). The continued discoveries within
the elds of neurology and neuroscience are the backdrop for theories
of pain that have since developed. These models have evolved
alongside our understanding of psychology, including emotions and
belief systems, the body, and people’s relationships to one another,
their environment and the world.
Gate Theory
One of the most inuential pain theories has been work by Melzack
and Walls (1965; Katz and Rosenbloom2015), which introduced the
concept of a gate mechanism within the nervous system that had the
ability to select the pain impulses travelling to the brain. They
proposed that nociceptive pain signals are transmitted from the
peripheral nervous system to the brain, where a pain response is
elicited. A specialised group of cells within the spinal cord functions
as a gate, enabling these impulses to be either allowed or blocked
from travelling to the brain. Where the gate is open pain is experienced,
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Holistic Management of Pain 289
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TABLE6.1
Opens the gate Anxiety
Closes the gate Happiness
Source: Adapted from Upton and Upton (2015).
Gate theory andinuences.
Cognitive and
Emotional
Worry
Tension
Depression
Optimism
Relaxation
behavioural Physical
Focusing on the pain
Boredom
Other reactions
More involvement and
interest in life’s
activities
Distractions or focus
on other activities
Other reactions
Extent and
type of injury
Low- level
activity
Medication
Counter-
stimulation,
e.g. rubbing
but where the gate is closed there is less pain. Pain signals are thereby
modulated, with specic inuences for deciding whether this gate
should be open or shut being multivariant, and having as much to do
with emotional, psychological and environmental factors as with the
injury or disease process itself. See Table6.1.
The theory has helped with understanding the function of the
dierent nerve bres (Melzack1996). The small peripheral nerve
bres directly communicate damage, with noxious stimuli opening
the gate, whereas activation of the large peripheral bres can
mediate to close the gate. Non-
painful sensations such as massaging,
rubbing around an area or the application of heat may have a
soothing eect, because in these instances the large peripheral bres
are being activated, inhibiting other pain signals (Upton and
Upton2015).
This theory has enabled insights into nursing the patient in
pain. It has assisted with understanding some of the inuences
that determine pain from a physiological perspective, but also in
considering the challenges and variables relating to pain management. Despite this, the theory continued to emphasise the presence
of a pathway to dene the nature and experience of pain, which
meant that persistent pain was not so easily addressed within
this model.
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290 HOLISTIC MANAGEMENT OF PAIN
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Biopsychosocial Model
With the development of successive theories and associated research,
it has become increasingly recognised that pain does not equate with
injury. Theories around pain and what contributes to the pain
narrative have increasingly sought to understand the complexity of
the experience. This has led to the recognition of the biopsychosocial
model as the most comprehensive and accepted model to date, with
pain now accepted as a biopsychosocial phenomenon and essential
in understanding the pain experience (Upton and Solowiej 2010;
Dueñas etal.2016).
This model emphasises the dynamic relationship between the
biological, social and psychological domains of a person’s life. As
there is no single pain centre in the brain, dierent parts are activated
according to the stimuli. These stimuli are always individually
perceived and experienced, being inuenced by the biopsychosocial
variables. This is termed the neurosignature (Lyman 2021) and is
unique to each person. Within this model the phenomenon of pain
will include:
Sensory aspects, as the brain seeks to determine where the danger
is coming from. This will include pathophysiological causes such
as wound aetiology, prolonged inammation, hypersensitivities,
venous insuciencies, local infection and pressure from neoplasms (Hollinworth2005) as well as ischaemia and dermatitis
(Briggs etal.2012), odour and exudate (Phillips etal.2018). The
release of inammatory molecules as part of the immune
response will contribute to inammatory processes and the
further sensitisation of nerves (Zhang and An2007).
Psychological, where the brain decides that the stimuli is a threat.
Emotional responses, such as moods, anxiety, depression, fear
and stress. See Table6.2.
Cognitive components, involving our memories, thoughts and
beliefs, which will include cultural backgrounds and religious
thinking, although these must not be used to infer stereotypes.
Beliefs also relate to self- ecacy and the extent to which people
believe that they can cope with pain, as well as to expectations.
These are important determinants within the therapeutic
relationship and in being able to tolerate pain.
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TABLE6.2 Impact ofpain onthe person.
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Eect of excessive pain
Stress
Woo (2010)
Upton and
Solowiej (2010)
Wynn and
Holloway (2019)
Anxiety
Colloca and
Beneddetti (2007)
Woo (2015)
Fear
Dueñas etal. (2016)
Lack of sleep
Upton and
Andrews (2013)
Green etal. (2017)
Negative emotions
and moods, feeling
threatened, lack of
control,
helplessness
Bair etal. (2003)
Woo etal. (2008)
Ballantyne and
Sullivan (2015)
Dueñas etal. (2016)
Pain is a major source of stress leading to:
Delayed healing.
Increased activity on the body’s immune and
hormonal systems, which raises the peripheral
immune response, increasing sensitivity to pain
and amplifying chronic stress.
Driving of inammation, prolonging the
inammatory phase of wound healing, which
increases pain and contributes to non- healing.
Pain is a major source of anxiety leading to:
More anxiety being experienced.
Nocebo eect: heightened anxiety in the
anticipation of pain giving higher ratings to the
pain experience and self- reported pain intensity.
Increased sensitivity to pain: lower pain
threshold and tolerance.
Predictor of procedural pain: increased
related pain at dressings and
woundbetween changes.
Delayed healing: impact of inammatory
mediators. Drives inammation that
increases pain.
Cycle of pain, stress, worsened pain and delayed
wound healing.
Increases the peripheral immune response,
increasing sensitivity to pain.
Can become a self- fullling prophesy as the
brain’s alarm system is elevated.
Combined with anxiety amplies to the brain
that all is not well.
Causes inammation, which increases pain.
Debilitates and adds to the pain cycle.
Lack of sleep can contribute to increased pain.
Can worsen short- term pain, which may
transition into long- term pain.
Pain is rated as more intense.
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