Practical Treatment of Wound Pain and Trauma: A Patient-Centered Approach. An Overview

Author(s): 
Madhuri Reddy, MD, FRCPC(Geriatric Med); Rosemary Kohr, RN, MScN, ACNP; Douglas Queen, BSc, PhD, MBA; David Keast, MD, FCFP; and R. Gary Sibbald, MD, FRCPC(Med)(Derm)

Unresolved pain is often associated with delayed wound closure.
The following important points should be heeded regarding pain management as it relates to wounds:
* Analgesics can have a negative impact on healing.
* Anti-inflammatory agents (NSAIDS) may reduce pain but may affect wound healing.
* Antidepressant or antiepileptic agents raise questions regarding the tissue repair processes.
Before clinicians consider treatment with analgesics or other treatment modalities, the source of pain should be thoroughly investigated and only interventions that will alleviate the real or potential injury to tissue should be initiated.

Pain Assessment
A thorough pain history is essential to wound pain management. The nature, onset, duration, and exacerbating and relieving factors will help determine the cause of the pain and direct strategies for relief. Nociceptive pain often is described as aching or throbbing; whereas, neuropathic pain may be described as burning, lancinating or electric shock like.
Pain intensity can be reliably measured using validated pain scales. Several pain scales (see Figure 1) have been widely accepted for use among older adults, including people with mild to moderate cognitive impairment. A verbally administered 0 to 10 scale is a good first choice for measuring pain intensity. If the patient has difficulty with the scale, other verbal descriptor scales, pain thermometers, and faces pain scales also have accepted validity and reliability in this population.4 The scale of choice should be appropriate for the individual and used consistently with each assessment.6 Although sensory and cognitive impairment may be present, pain can usually be assessed accurately using techniques adapted for the individual's disabilities.7,8
Older patients may make pain assessment challenging.14,15 Many patients and their families accept pain as an inevitable consequence of aging, do not believe pain can be treated, may fear diagnostic tests, and/or assign too much importance to hypothetical medication side-effects or addiction.4 A patient with severe dementia who suffers from pain presents a particular challenge. In this case (or in the case of a nonverbal patient) pain can be assessed by directly observing the patient or obtaining a history from caregivers. Patients should be observed for evidence of pain-related behaviors during movement or dressing changes. Deteriorating cognitive status or agitation also should elicit assessment for pain as a potential cause.4 Whether the presence of dementia affects the experience of pain is not known.16 Therapeutic experience dictates that clinicians should have a high index of suspicion regarding pain when people with cognitive impairment have diseases associated with significant pain (chronic wounds, arthritis, ischemia, cancer).
Patients with persistent pain should be reassessed regularly for improvement, deterioration, or adherence to medication regimens. The use of a pain diary with entries regarding pain intensity, medications used, mood, and response to treatment may be a good management strategy.4 Many barriers exist to optimal pain management (see Table 1).

Pain Management
The management of wound pain can be integrated into the wound management paradigm19: treat the cause and address local wound factors and patient-centered concerns (see Figure 2). Treating the cause should determine the correct diagnosis and initiate treatment of the wound pain. Patient-centered concerns must focus on what the patient sees as the primary reasons and resolutions for the pain. Patient anticipatory pain and suffering can be just as disruptive to quality of life as the actual experience of pain. Local wound care needs to revolve around the three pillars of local wound care practice: debridement, bacterial balance/prolonged inflammation, and moisture balance.

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