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Ostomy Wound Management
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Understanding Venous Leg Ulcer Pain: Results of a Longitudinal Study
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Venous leg ulcer pain experienced during compression bandaging is poorly understood. A prospective, pilot cohort study was initiated to determine the feasibility of conducting a large-scale, repeated measures cohort study of venous leg ulcer pain and to document and describe the venous leg ulcer pain experience during the first 5 weeks of treatment with compression bandages. Eligible individuals admitted to a nurse-led community leg ulcer service in one Canadian community were recruited for the 5-week study. Pain assessment tools (ie, numerical rating scale and short form McGill Pain Questionnaire) were evaluated by 20 venous ulcer patients (mean age = 73.7 years) and their nurses for ease of use during one baseline and five weekly follow-up visits. Health-related quality of life (HRQL) information was obtained. Nurses reported on ease of integrating pain data collection into regular clinical care. Each pain assessment tool was audited for completion. Most participants found the pain assessment tools easy to use, but nurses reported lengthened visit times with some participants as a result of tool administration difficulties, particularly the visual analogue scale (VAS). Overall completeness of pain assessment tools ranged from 85.0% (visual analogue scale) to 96.3% (present pain intensity and word descriptor list). The vast majority of patients (18) reported ulcer pain at baseline. Total mean scores for all pain assessment tools used decreased over time, but most patients reported pain throughout the study. The most common pain descriptors used were "aching," "stabbing," "sharp," "tender," and "tiring." Health-related quality of life was low and did not change during the 5-week study. The results of this study suggest that the vast majority of venous ulcer patients experience pain and that it is feasible to examine this pain in individuals receiving care in the community over time.
Literature Review
In Western countries, the prevalence rate of leg ulceration is 0.6 to 3.6 per 1,000.1 For many, the ulceration lasts for months, and for some, decades. Two-thirds will have at least one recurrence.2-4 Many also experience pain.5-7 Venous ulcers account for a large proportion of leg ulcers.2-4.8,9 Individuals with venous leg ulcers experience decreased health-related quality of life (HRQL).10-17 A significant component of decreased HRQL is thought to be related to pain.11,13,14,16,17 In the authors' study setting, where the prevalence of venous leg ulcer pain was examined over three seasons, the prevalence of pain ranged from 48% to 54%.18 Other studies have documented reports of pain in 28% to 93% of their patient population.4,8,12,15,17,19-21
Factors associated with venous leg ulcer pain are poorly understood. Compression bandaging, the gold standard treatment for venous leg ulcers,22 is thought by some to be associated with venous leg ulcer pain,14,19,23-25 further confounding clear understanding of the venous ulcer scenario. In addition, because the findings in these studies contradict one another as to whether this therapy alleviates or exacerbates pain, no conclusions can be reached. These findings are limited by assessment of pain using relatively non-validated and unreliable pain measures. However, the importance of pain has been recognized in a recent international position paper26 that has called for greater emphasis of the patient perspective in research.
A better understanding of the pain that may or may not be associated with compression is necessary to improve the overall management of this chronic, recurring condition. Full understanding will only come from a large, prospective, repeated measures cohort study using validated pain assessment tools to determine relationships between compression therapy and pain as well as the natural course of pain in the process of healing an active venous ulcer.
Therefore, the purpose of this study was to: 1) determine the feasibility of conducting a large, repeated measures cohort study of venous leg ulcer pain, and 2) document and describe the venous leg ulcer pain experienced by the cohort of individuals during the first 5 weeks of compression bandaging. The feasibility issues were four-fold and focused on: 1) recruitment, willingness to participate, and study retention, 2) integration of pain data collection into usual clinical routine, 3) acceptance and ease of use of pain assessment tools by clinicians and individuals with leg ulcers, and 4) the quality and completeness of data collection. The 5-week timeframe represents a clinically meaningful period when the initial application and adjustment to compression bandaging occurs. It also represents a time period during which complete healing of a venous leg ulcer would not have occurred in most individuals. A secondary purpose of the study was to describe the experience of pain using this small sample.
Pain and venous leg ulcers. Venous leg ulcer pain is thought to be complex, varying in intensity, and involving continual pain as well as acute pain in response to treatments.10,14 Venous leg ulcer pain also has been shown to be of both nociceptive (ie, arising from the stimulation of intact afferent nerve endings)13-15 and neuropathic (ie, arising from peripheral nerve damage) origin.10,13-16
The pain associated with venous leg ulcers is an important clinical issue. Recent clinical practice guidelines recommend that leg ulcer management should include regular pain assessment.27-31 However, these guidelines do not recommend specific instruments or methods to measure pain with the leg ulcer population. Two aspects of assessment are crucial: self-reported pain and the use of valid and reliable tools.32 To meet these criteria, some tools assess pain intensity (eg, numerical rating scale [NRS],33 verbal descriptor scale [VDS],34 or a visual analogue scale [VAS]35), while others address the quality of pain (ie, sensory and affective [short form McGill Pain Questionnaire -SF-MPQ]36 or the impact of pain on an individual's life (eg, Brief Pain Inventory).37
Given the complexity of venous leg ulcer pain, the measurement should include both intensity and quality of pain. This can be accomplished by using a two-step method, specifically assessing for the presence and intensity of pain (NRS or VAS) and if pain is present, describing the quality of the pain using the SF-MPQ.
Methods
Study design, sample, and setting. Over a 3-month period (February 1, 2002 to April 30, 2002), a prospective, pilot cohort study of pain was conducted with people attending a community leg ulcer service (care in the home and two clinics) in a large urban-rural region of Eastern Ontario, Canada (population 1,000,000). The nurse-led service is based on a primary nursing delivery model38,39 and staffed by registered nurses with special training in the assessment (Doppler use, ankle-brachial pressure index) and management (compression bandaging technology) of venous leg ulcers. An evidence-based protocol40 provides the multidisciplinary standard of care and is used by the community nurses as well as the consulting physicians (eg, family medicine, dermatology, vascular surgeons) in this region. The 3-month timeframe was selected because it represents an operational quarter year and would provide adequate exposure to client flow, range of cases, and usual variation of clinical service before and after holiday periods.
During the early treatment period, the number of times an individual with a venous leg ulcer is seen is dictated by the amount of leg edema and exudate. The minimum is once weekly, allowing for regularly timed, repeated measures of pain. Pain data were collected on the day closest to the seventh day from the previous study visit when the individual had more than one visit in a week.
Study inclusion criteria included: 1) English-speaking, 2) newly admitted with an active leg ulcer of pure venous or mixed etiology (ie, venous and arterial), 3) prescribed compression bandaging, and 4) capable and willing to complete the required pain assessment tools six times over 5 weeks or until the leg ulcer had healed, whichever came first. A nurse assessed etiology during the initial leg ulcer service visit using a standardized clinical assessment including an ankle brachial pressure index measure with hand-held Doppler. The study was approved by the Research Ethics Board of the Ottawa Health Research Institute.
The leg ulcer service nurses attended an inservice regarding the study 1 month before the start. Study objectives, inclusion and exclusion criteria, pain assessment procedures, timing for research repeated measures, and procedures for data management between the research office and the leg ulcer service were reviewed.
Recruitment and consent process. The clinical service receives daily referrals for individuals with leg ulcers from the local regional home care authority. From this roster, the clinical manager identified potential study participants and a phone message was left for the attending nurse who would be handling admission assessment. A study package was placed on the chart indicating a potential study participant. The study data collection procedure mirrored usual clinical care except pain assessments were more comprehensive and frequent and HRQL assessment was added. During the admission visit (T1), the nurse confirmed the individual's eligibility for the study, explained the study, and obtained and noted verbal consent to participate if the patient were agreeable.
Measures and data collection.
Feasibility. Potential study candidates were entered into a tracking log maintained at the clinic. Eligibility and willingness to participate in the study were recorded. The proportion of individuals currently attending the service and those who were eligible and willing to participate in the study were tabulated from the log.
Nurses provided their perceptions of the integration of the research data collection with usual clinical routine and the ease of use of the pain measures. In a debriefing session, the nurses responded to open-ended questions about their experience assessing pain for the study. The session was conveniently organized during one of the team's regular meetings, after pre-circulating the questions. At the end of the study, information related to ease-of-use tools was obtained from the participants by asking whether they found the tools easy to use, and each of the participant's weekly assessment tool forms was audited for completeness.
Pain and health-related quality of life. Sociodemographic (eg, age, gender), circumstance-of-living (eg, living arrangements, self-care), and clinical variables (eg, comorbid conditions, previous leg ulcers) (see Table 1) were obtained from the admission data to develop a descriptive profile of the study sample. These data, which are routinely collected on admission to the leg ulcer service, were downloaded from the service database.
For the two-step process, the NRS (0 to 10) and two components of the SF-MPQ, the present pain intensity (PPI) (ie, list of six number-word combinations), and a 10-cm VAS were used in Step One. The 15-word descriptor list (ie, 11 sensory words and four affective words) of the SF-MPQ was used to obtain information regarding the quality of pain in Step Two. The reliability and validity of the NRS41-44 and the SF-MPQ45-47 have been documented in the literature. Information on pain medication use was collected at admission and each visit; study participants were asked if they had taken pain medications for leg ulcer pain in the last week - if so, they were asked to list them. The attending nurse assessed pain intensity and quality, as well as pain medication usage, at admission and weekly during a regularly scheduled visit for the next 5 weeks (T1 to T6). At baseline, individuals were asked about pain "in the last 24 hours," and on subsequent visits, the timeframe became "in the last week." The collection of baseline pain data is considered a necessary step to determine the efficacy of pain management strategies.48 The timeframe "in the last 24 hours" was selected for T1 to clinically determine if the individual had pain before compression therapy started. Calculating a pain score based upon recall within a 1-week timeframe is supported by previous study results.49,50 Pain can be categorized as none, mild, moderate, or severe (verbal descriptor scale). For the visual analogue scale, pain scores of 30 mm or less, 30 to 54 mm, and 55 mm and greater represent mild, moderate and severe pain, respectively.51
Health-related quality of life was assessed with a generic scale (the Short Form Health Survey [SF-12])52 at admission (T1) and 5 weeks (T6). This survey consists of 12 questions - six related to physical health and six to mental health. The SF-12 has been used to examine HRQL in various chronic conditions (eg, heart failure and hypertension) including the chronic wound group. The survey has been found to be easy to administer and has demonstrated reliability and validity.52
Data analysis. Quantitative data were entered into the Statistical Package for Social Sciences (SPSS) (Version 11.0). Data management for the qualitative data derived from the debriefing session was facilitated by reviewing the field notes and entering them into the MS-Word software program. Themes were extrapolated and analyzed using content analysis techniques.53
Completeness of data collection for each pain measure was calculated over the six time periods. To develop the profile of the pilot study participants, descriptive statistics (frequencies, means) were compiled on sociodemographic, clinical, and circumstance-of-living variables and pain medication use. The frequency distributions of the VAS, NRS, and PPI scale and sensory and affective word descriptor pain scores were calculated for each of the six study time points to determine pain intensity. Mean pain scores of the VAS, NRS, PPI scale, total word descriptor list, and sensory and affective word descriptors, as well as individual participants' pain scores for these measures, were plotted over the 5-week study period to visualize the pain intensity associated with compression therapy over time. To examine the quality of venous leg ulcer pain, the frequency distributions of the sensory and affective word descriptors selected by the participants were calculated over the six periods. Paired t-tests were used to assess differences in pain scores between each of the six time periods and HRQL scores at baseline (T1) and after 5 weeks of care (T6).
Results
Description of the pilot cohort group. Of the 42 potential study participants, all but two (5%) were screened for the study and 22 out of 40 (55%) were eligible for the study. Reasons for ineligibility included not being prescribed compression therapy (n = 12), cognitive impairment (n = 4), planned hospitalization for another condition (n = 1), or aphasia (n = 1). Of the 22 eligible participants, 20 (91%) agreed to participate. In total, 19 individuals completed the pilot study; one individual was lost to follow-up because she was hospitalized at T4. Two individuals healed before the sixth study point (one after the first week of compression [T2], the other after 4 weeks [T5]). Eleven registered nurses participated in the pilot, representing 85% of the service nurses.
The pilot group presented as predominantly elderly (mean age = 73.7 years) and female (60%) (see Table 2). On admission to the leg ulcer service, the majority had a diagnosis of pure venous leg ulcer (80%); a history of precipitating venous disease factors (85%) and previous leg ulcers (40%); leg edema (90%) that was located mainly in the mid-calf to knee area (75%); partial-thickness leg ulcer depth (70%); and leg ulcers less than 2.5 cm2 (56%). Of the group, 80% experienced comorbidities, 50% were not independently mobile, and 50% had self-care problems. Approximately half were prescribed high compression (45%) and low compression bandaging (45%) with the remaining 10% receiving stocking support.
Integrating pain data collection with clinical care. None of the nurses reported that weekly pain assessments interfered with their routine. However, during the debriefing session it was noted that administration of the measures lengthened the visit of some participants. This was due to the need to explain the meaning of word descriptors and the extra instruction required to complete the NRS and PPI scale (eg, explaining the need to provide only one score and not a range of scores). The measurement and transcription of the VAS score was thought to be time consuming. Also of note was the perception that the length of a typical visit increased because reviewing and scoring each word descriptor took time. The nurses' preference was to forego the use of the word descriptor list and instead to ask the individual to describe the quality of their venous leg ulcer pain in their own words.
Ease of use of the pain assessment measures. Of those participants providing feedback regarding the pain assessment tools (n = 13), 85% found them easy to use. The nurses (n = 11) reported that they were easy to administer (VAS 100%; NRS and PPI scale and word descriptor 91%). The debriefing session revealed that some nurses preferred to use the NRS because it offered an immediate score, unlike the VAS where measuring and transcribing were necessary. Nurses also reported that factors such as physical frailty and poor eyesight might have contributed to VAS completion errors (eg, instances of x's or check marks that were far off the line).
Completeness of the pain assessment data collection. Overall completeness of the pain assessment tools on all items over the 5 weeks ranged from 85% (VAS) to 96% (PPI scale and word descriptor list) (see Table 3). Problems related to the VAS included participants making a very thick line and check marks or an x marks above or below the line. With the NRS, the main issue was individuals providing a range of scores (ie, 7 to 8). The problems identified with the PPI scale and word descriptor list were the presence of two scores or the omission of a score. By T6, the proportion of individuals incorrectly or not completing the VAS was higher than at T1 (T1, 10% and T6, 19.0%). However, the majority of incorrectly completed pain assessment tools were isolated to specific individuals. In addition, some missing data from T4 to T6 occurred because the leg ulcer service nurses did not administer the tools. During the debriefing session, many of the nurses indicated they were not always able to review pain assessment tools at each visit, mainly due to time constraints.
Pain and HRQL during the 5 weeks of compression therapy. At admission, 18 individuals (85%) reported pain related to their leg ulcer; of these 11 (61%) reported moderate to high levels. At T6, only slightly fewer (13, 81%) continued to report some pain, but it was less severe. Over the 5-week study period, a trend was seen with decreases in the total mean pain scores on all the pain assessment measures (see Figures 1 and 2). The total T1 mean pain intensity score for the NRS was significantly higher (P <0.05) than the T4 score (t-2.2, P = 0.05). The total T1 mean pain intensity score for the PPI scale was significantly higher (P <0.05) than the T2, T4, and T6 scores (T1 versus T2: t-2.4, P = 0.03, T1 versus T4: t-2.3, P = 0.04, T1 versus T6: t-2.6, P = 0.02). The total T1 mean pain intensity score for the SF-MPQ sensory word descriptors was significantly higher (P <0.05) than the T6 score (t-2.3, P = 0.04). The three individuals without pain at T1 continued to report no pain during the study. Individuals described their venous leg ulcer pain each week by selecting several word descriptors. The sensory words selected most often were "aching," "stabbing," "sharp," "tender," and "tiring." One individual added the word "stinging" with a pain score at each weekly assessment. For each word descriptor, excluding the word "fearful," the proportion of individuals selecting a word and the mean pain intensity score decreased over the six time periods.Figure 1
|  | | Weekly mean VAS, NRS and PPI pain scores in individuals during 5 weeks of compression bandaging. |
At admission, nine (53%) individuals with venous leg ulcer pain were taking prescription pain medication (see Table 2). Of these, the majority was prescribed an opioid (67%). Many (66%) of those who were prescribed pain medication for their venous leg ulcer pain used it. Fewer reported pain medication use by T6.
In this small cohort, the HRQL changed little during the first 5 weeks in care. From baseline to 5 weeks, mean physical health component scores ranged from 33.0 to 36.0 and mean mental health component score from 50.0 to 54.0. These differences were not statistically significant.
Discussion and Limitations
This pilot cohort study examined venous leg ulcer pain experienced by individuals during compression therapy over time using validated pain assessment tools. The profile of the 20 participants is similar to the sociodemographic, circumstance-of-living, and clinical characteristics reported in previous prevalence studies (n = >400, part of the ongoing quality processes). Thus, it is probably representative of those with venous leg ulcers being cared for in the larger community. The majority (85%) in the pilot reported pain on admission for care, demonstrating that pain is clearly an issue for this population. This rate is higher than what has been reported in other studies4,20 and lower than one other study.12 The observed difference may reflect the effect of sampling newly admitted patients only, as occurred in this study, versus sampling a cross-section of people receiving care. Figure 2
|  | | Weekly mean total word descriptor pain scores in individuals during 5 weeks of compression bandaging. |
The majority of the individuals examined in other studies would have received care for more than 5 weeks, with some receiving care for more than 1 year.4,8,19 In addition, with compression, pain changed over time. Notwithstanding the small sample size, statistically significant improvements in pain levels were seen during the 5 weeks in care and all individuals were using compression of some kind. However, a sizable portion reported pain at the fifth week of care; therefore, future research should involve a longer study timeframe (eg, until healing occurs if possible).
The participants in this pilot cohort had lower mean physical health component scores when compared to SF-12 results of individuals with other chronic conditions (eg, 36 compared to 46.1 for hypertension and 45.7 for type II diabetes).54 This comparison is indicative of the negative impact of having a venous leg ulcer on HRQL relative to other prevalent chronic conditions.
Conducting this pilot cohort in a pragmatic, clinically realistic fashion and using attending staff to assist in data collection during usually scheduled visits were quite achievable. The research protocol was acceptable to patients, nurses, and the service setting. Once on study protocol, the completion rate was high. In considering the conduct of a large cohort study of venous leg ulcer pain, a number of valuable lessons were learned from this pilot study regarding recruitment, data collection procedures, the "fit" with clinical routines, and the use of valid and reliable pain measures.
The use of a service-based, research tracking log provided valuable and timely data on those eligible and willing to participate. In the large service setting collaborating with researchers in the pilot study, the majority (91%) of eligible individuals were willing to participate, which is encouraging for future studies. Although the number of patients who were not approached was low (two out of 42), this information alerts researchers to the need for careful procedures to ensure that eligible individuals are not missed. The eligibility and willingness to participate log will facilitate planning a future study with regard to sample size calculation and selection of the number and size of sites required to accrue the sample in a reasonable timeframe.
Overall, the pain and HRQL measures used in the pilot were found to be acceptable to individuals with leg ulcers. The two-step method of assessing pain presence first, followed by an in-depth assessment of pain quality if pain was reported, worked well clinically. It was an efficient use of the attending nurse's time and closely emulates normal clinical routine of asking if a patient is experiencing pain first followed by further questions if the patient responds that he/she has pain. In normal routine care, nobody would ignore the patient's response and not request further information about the quality of pain. The VAS and NRS provide reliable and valid measures to detect the presence of pain and its intensity. Either the VAS or the NRS could be used for the initial assessment followed by the SF-MPQ to describe the quality of pain if present. In this study, these widely used pain measures were found to be sensitive to changes in pain levels with leg ulcers. An advantage of using generic pain measures is that comparisons of pain levels experienced with venous leg ulcers to pain experienced from other conditions can be made.
Because of the need to track leg ulcer pain over time, the burden of administration and "fit" of pain research data collection with usual care will be crucial to the success of a large study. The nurses perceived that visits were longer as a result of administering the pain measures, although this could not be validated through existing data sources (eg, average visit time over the study period and/or changes in the clinic or home visit schedules). It may be that the nurses were simply adding it onto their day, knowing that this was a time-limited pilot study. However, the good will would likely run out before completion of a large cohort study in a study of longer duration. The time constraints of a busy clinic or home visit schedule may supersede research data collection and the study would be compromised with incomplete data. Before commencing on a large study, time and workload issues would have to be resolved. To ameliorate the incremental impact of the research data process for recruitment and data collection, the budget should include adequate remuneration to the service for the incremental cost of added nursing time. In this way, daily clinic or home visit schedules for nurses could be reduced if necessary.
In a larger study, data collection over time would need to be closely monitored. In the pilot study, as time in study progressed, instances of incorrect completion of the VAS and NRS and non-administration of the tools by nurses increased. This was a small proportion and isolated to a few participants but could be an important issue in a larger cohort. Regular monitoring of weekly completion rates with particular attention to individuals older than 80 years is advised. Quality and service time-saving procedures to improve data collection and decrease the burden on the clinical setting could be performed by a research assistant and include: 1) approaching identified potential participants with study information and consent, 2) verifying participant ability to complete the pain assessment tools, 3) providing instructions regarding proper use of the tool, 4) reviewing every study chart each week, and immediately following-up with the attending nurse if errors or omissions are noted, and 5) calculating and monitoring weekly completion rates of measures.
This pilot study used a small convenience sample and as such, should be interpreted carefully in terms of the pain data. It represents the number of patients normally seen in one large regional service during a 3-month period with less than 5% missed and virtually all eligible individuals enrolled in the study. The validity of the pain measures within the venous leg ulcer population has not been adequately studied because use and psychometric testing of pain assessment tools with this population has been limited
The reliability of data collected by clinical staff rather than research staff may be viewed as less than ideal. However, attending nurses know their patients and may receive more accurate assessments than a stranger. Practically speaking, conducting research in a home care environment where research staff would shadow each nurse would be logistically challenging and costly because venous leg ulcer patients are not the only patients seen. On the other hand, not following the regularly planned visit means inconvenience for the patient. With adequate orientation to the study and data collection procedures, it was practical and efficient for nurses to collect repeated measures on pain. The possibility of social response bias in either over-reporting or under-reporting pain (ie, patients not wanting to complain) always exists; however, this did not seem to be a factor in this study. Patients indicated they were pleased to be asked about their pain and freely shared their negative and positive perceptions. Finally, the potential problem of spurious results exists because a large number of statistical tests were performed and corrections (eg, Bonferroni procedure) to compensate for this were not performed. However, this pilot study was not powered to detect differences.
Conclusion
This pilot study provided important information for clinicians and researchers about venous leg ulcer pain - ie, it is an important issue in the care of the leg ulcer population. Patients reported pain at admission and for many pain was still present, though less severe, after 5 weeks in care. Based on the results obtained, conducting a large study of venous leg ulcer pain with clinical staff collecting research data and research staff supporting the process with rigorous quality procedures would be a reasonable next step. The reliable and valid generic pain measures used were found to be sensitive to changes in self-reported leg ulcer pain. The SF-MPQ captured the complexity of venous leg ulcer pain over time. Future research that allows for the addition of word descriptors will assist in evaluating the appropriateness and completeness of the SF-MPQ list for use by those with leg ulcers.
Examining and understanding the factors associated with venous leg ulcer pain (eg, edema, leg ulcer size, exercise, and type of compression and dressings) is important to the design of intervention studies, as is tracking individual perception of need for pain medication and pain medication usage. To respond to these issues, further studies should be directed at understanding the experience of pain during treatment with compression therapies and healing. The lessons learned from this pilot study will contribute to the preparation and design of a large-scale pragmatic trial and were recommended in the international position document on wound pain.26 The ideal plan would be to use a repeated measures design over a timeframe from admission to care until healing or at least 12 months. Such a study would be a valuable contribution to resolving current gaps in knowledge of venous ulcer pain. Ultimately, the effectiveness of nursing care with this population will be dependent on improved assessment and management of pain with this condition. - OWM
Acknowledgements
This work has been supported in part by a Social Sciences and Humanities Council research grant (#839-2000-1014). Margaret Harrison is an Ontario Ministry of Health Career Scientist. Ian Graham is a Canadian Institutes of Health Research New Investigator. The authors wish to acknowledge the support received from the patients; the Victorian Order of Nurses; Karen Lorimer, Clinical Manager of the Ottawa-Carleton Regional Leg Ulcer Service; the Ottawa-Carleton and the Regional Leg Ulcer Service tea]; and the expert assistance from Research Analyst Elaine Friedberg, RN, MHA, Ottawa Health Research Institute. |
1. Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A. A systematic review of prevalence studies of lower limb ulceration. Advances in Skin and Wound Care. In press.
2. Baker SR, Jopp-McKay AG, Hoskin SE, Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg. 1991;78:864-867.
3. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic ulcer of the leg: clinical history. BMJ. 1987;294(6584):1389-1391.
4. Nelzen O, Bergqvist D, Lindhagen A. Venous and non-venous leg ulcers: clinical history and appearance in a population study. Br J Surg. 1994;81:182-187.
5. Hamer C, Cullum N, Roe B. Leg ulcers. In: Hamer C, Cullum N, Roe B (eds). Nursing Management: A Research-based Guide. Harrow, UK: Scutari Press;1995.
6. Harrison MB, Graham ID, Friedberg E, Lorimer K, Vandevelde-Coke S. Assessing the population with leg and foot ulcers. Canadian Nurse. 2001;97(2):18-23.
7. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. Quality of life in chronic leg ulcer patients. Acta Derm Venereol Suppl Stockh. 1993;73:440-443.
8. Ebbeskog B, Lindholm C, Ohman S. Leg and foot ulcer patients. Scand J Prim Health Care. 1996;14(4):238-243.
9. Stevens J, Franks PJ, Harrington M. A community/hospital leg ulcer service. Journal of Wound Care. 1997;6(2):62-68.
10. Chase SK, Melloni M, Savage A. A forever healing: The lived experience of venous ulcer disease. Journal of Vascular Nursing. 1997;15(2):73-78.
11. Ebbeskog B, Ekman SL. Elderly persons' experiences of living with venous leg ulcer: Living in a dialectal relationship between freedom and imprisonment. Scandinavian Journal of Caring Sciences. 2001;15:235-243.
12. Hofman D, Ryan TJ, Arnold P, Cherry GW, Lindholm C, Bjellerup M et al. Pain in venous leg ulcers. Journal of Wound Care. 1997;6(5):222-224.
13. Husband LL. Venous ulceration: the pattern of pain and paradox. Clin Effectiveness Nurs. 2001;5:35-40.
14. Krasner D. Painful venous ulcers: themes and stories about their impact on quality of life. Ostomy/Wound Management. 1998;44(9):38-49.
15. Noonan L, Burge SM. Venous leg ulcers: is pain a problem? Phlebology. 1998;13:14-19.
16. Walshe C. Living with a venous leg ulcer: a descriptive study of patients' experience. J Adv Nurs. 1995;22:1092-1100.
17. Wissing U, Ek AC, Unosson M. Life situation and function in elderly people with and without leg ulcers. Scandinavian Journal of Caring Sciences. 2002;16:59-65.
18. Nemeth K, Harrison MB, Graham ID, Burke S. Pain in pure and mixed etiology venous leg ulcers: a three-phase point prevalence study. Journal of Wound Care. 2003;12(9):336-340.
19. Franks PJ, Moffatt CJ, Connolly M, Bosanquet N, Oldroyd M, Greenhalgh RM, et al. Community leg ulcer clinics: effect on quality of life. Phlebology. 1994;9:8386.
20. Lindholm C, Bergsten A, Berglund E. Chronic wounds and nursing care. Journal of Wound Care. 1999;8(1):5-10.
21. Smith JJ, Guest MG, Greenhalgh RM, Chir M, Davies AH. Measuring the quality of life in patients with venous ulcers. J Vasc Surg. 2000;31:642-649.
22. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for Venous Leg Ulcers. Oxford, UK: The Cochrane Library;2000.
23. Bliss MR, Schofield M. A pilot leg ulcer clinic in a geriatric day hospital. Age Ageing. 1993;22:279-284.
24. Brereton L, Morrell J, Collins K, Walters S, Peters J, Brooker C. Patients' tolerance of leg ulcer treatments. British Journal of Community Health Nursing. 1997;2(9):427-435.
25. Pieper B, Rossi R, Templin T. Pain associated with venous ulcers in injecting drug users. Ostomy/Wound Management. 1998;44(11):54-67.
26. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. In: Caine S, ed. Pain at Wound Dressing Changes. London, UK: Medical Education Partnership Ltd.;2002:2-7.
27. Clinical Resource Efficiency Support Team. Guidelines for the Assessment and Management of Leg Ulceration. Recommendations for Practice. Belfast, Ireland: Clinical Resource Efficiency Support Team;1998.
28. Compliance Network Physicians/Health Force Initiative. Guidelines for the Outpatient Treatment of Chronic Wounds and Burns. Berlin, Germany: Compliance Network Physicians/Health Force Initiative;1999.
29. New Zealand Guidelines Group. Care of People with Chronic Leg Ulcers. Auckland, New Zealand: New Zealand Guidelines Group;1999.
30. Royal College of Nurses. The Management of Patients with Venous Leg Ulcers. Manchester, UK: Royal College of Nurses Institute;1998.
31. Scottish Intercollegiate Guidelines Network. The Care of Patients with Chronic Leg Ulcer. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network;1998.
32. Nemeth K, Graham ID, Harrison MB. The measurement of leg ulcer pain: identification and appraisal of pain assessment tools. Advances in Skin and Wound Care. 2003;16(5):260-267.
33. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Annals of the Rheumatic Diseases. 1978;37:378-381.
34. Keele KD. The pain chart. The Lancet. 1948;July 3:6-8.
35. Huskinsson EC. Measurement of pain. The Lancet. 1974;9:1127-1131.
36. Melzack R. The short-form McGill pain questionnaire. Pain. 1987;30:191-197.
37. Daut RL, Cleeland CS, Flanery RC. Development of the Wisconsin brief pain questionnaire to assess pain in cancer and other diseases. Pain. 1983;17:197-210.
38. Manthey M. A theoretical framework for primary nursing. J Nurs Adm. 198010(6):11-15.
39. Lorimer, K. The design and implementation of a nurse-lead community leg ulcer service. Masters Thesis. Unpublished Masters Thesis, University of Ottawa, Ottawa.
40. Graham ID, Lorimer K, Harrison MB, Pierscianowski T. Evaluating the quality and content of international clinical practice guidelines for leg ulcers: preparing for Canadian adaptation. Canadian Association of Enterostomal Therapy Journal. 2000;19(3):15-31.
41. Ekblom A, Hansson P. Pain intensity measurments in patients with acute pain receiving afferent stimulation. J Neurol Neurosurg Psychiatry. 1988;51:481-486.
42. Ferraz MB, Quaresma MR, Aquino LRL, Atra E, Tugwell P, Goldsmith CH. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol. 1990;17(8):1022-1024.
43. Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nurs. 1997;20(2):88-93.
44. Puntillo KA, Neighbour ML. Two methods of assessing pain intensity in English-speaking and Spanish-speaking emergency department patients. Journal of Emergency Nursing. 1997;23:597-601.
45. Dudgeon D, Raubertas RF, Rosenthal SN. The short-form Mcgill pain questionnaire in chronic cancer pain. J Pain Symptom Manage. 1993;8(4):191-195.
46. Helme RD, Katz B, Gibson S, Corran T. Can psychometric tools be used to analyze pain in a geriatric population. Clinical & Experimental Neurolology. 1989;26:113-117.
47. Seymour RA. The use of pain scales in assessing the efficacy of analgesics in post-operative dental pain. Eur J Clin Pharmacol. 1982;23:441-444.
48. Ho K, Spence J, Murphy MF. Review of pain assessment tools. Ann Emerg Med. 1996;27(4):427-432.
49. Salovey P, Smith AF, Turk DC, Jobe JB, Willis GB. The accuracy of memory of pain. APS Journal. 1993;2(3):184-191.
50. Singer AJ, Kowalska A, Thode HC. Ability of patients to accurately recall the severity of acute painful events. Acad Emerg Med. 2001;8:292-295.
51. Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres. Pain. 1997;72:95-97.
52. Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220-233.
53. Morse JM, Field PA. Qualitative Research Methods for Health Professionals, 2nd ed. London, UK: SAGE Publications Inc.;1995.
54. Ware JE, Kosinski M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales, 2nd ed. Boston, Mass.: The Health Institute, New England Medical Center;1995.
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| Ostomy/Wound Management - ISSN: 0889-5899 - Volume 50 - Issue 1 - January 2004 - Pages: 34 - 46 | |
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