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

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)

Other dressing-related factors that can cause pain include the dressing absorbency mechanism; dressing adherence; friction between dressing surface and wound bed; dressing/granulation tissue integration; and the presence of allergens.
Moisture balance (dressing performance). The way a dressing absorbs and manages exudate not only affects the physical performance of the material but also impacts wound pain. A dressing will adhere to the wound if it absorbs too aggressively or if the primary dressing allows strikethrough, adhering to secondary layers or regimens. Adhesion of primary and secondary products can result in the accidental traumatic removal of the primary contact layer and cause damage (and pain) to the wound bed.
Fibrous products (eg, alginates and hydrofibers) are excellent primary contact layers. They are gel-formers; as a result, they bathe the wound bed in a soft soothing gel. This allows nontraumatic removal and generally provides pain relief.
Some dressings are abrasive and can cause friction or adherence to the wound surface (eg, some gauze-based products). This can be avoided by using appropriate dressings (eg, gels/foams) or utilizing a nontraumatic wound contact layer (eg, soft silicone dressings). Research has shown these products to be relatively atraumatic upon removal.57
Adhesive dressings, as the name suggests, can be traumatic to both the wound bed and the periwound area. Films and hydrocolloids should be removed with care as recommended by the manufacturer's instructions.
Hydrocolloids are generally nonadherent to the wound bed because they form a soft, conforming gel in the presence of exudate.58 Care should be taken upon removal, however, to ensure no skin stripping of the periwound area.59 Again, appropriate use will prevent damage and pain and provide an effective moist wound environment.60
Care also should be exercised regarding the choice of dressing or other topical treatment regarding allergens that can cause uncomfortable or painful inflammation (ie, allergic response). Use of products with a high sensitization potential (eg, neomycin, Bacitracin, lanolin, and perfumes) in patients with leg ulcers should be avoided.61
Wound pain as a result of inappropriate local wound care generally can be corrected. A well-devised local wound care regimen with the appropriate elements (dressings for moisture balance, bacterial balance/controlled inflammation, and autolytic debridement where appropriate should be patient, wound, and disease specific (see Table 7).

Pain is often neglected because no simple diagnostic test exists to measure it. Quite simply, "Pain is what the patient says it is." Too often clinicians ignore pain because it is not easy to measure, yet unrelieved pain may seriously hamper efforts to heal chronic wounds. A paradigm that integrates pain management into an approach to wound bed management provides the clinician with a framework for improved care. An approach to chronic wound pain management that treats the cause and addresses local wound factors may lead to improved outcomes as patients may be more adherent to optimal care plans. A patient-centered regimen ensures appropriate care in a reduced pain environment (see Table 8). - OWM


1. Wulf H, Baron R. The theory of pain. In: European Wound Management Association. Pain at Wound Dressing Changes: A Position Document. 2002.
2. Dougherty PM, Palecek J, Paleckova V, Willis WD. Infusion of substance P or neurokinin A by microdialysis alters responses of primate spinothalamic tract neurons to cutaneous stimuli and to iontophoretically released excitatory amino acids. Pain. 1995;61:411-425.
3. Dickenson AH, Chapman V, Green GM. The pharmacology of excitatory and inhibitory amino acid-mediated events in the transmission and modulation of pain in the spinal cord. Gen Pharmacol. 1997;28:633-638.
4. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 2002;50:S205-S224.
5. Krasner D. Caring for the person experiencing chronic wound pain. In: Krasner D, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care, 3rd ed. Wayne, Pa.: HMP Publications;2001.
6. Ferrel BA. Pain. In: Osterweil D, Brummel-Smith K, Beck JC, eds. Comprehensive Geriatric Assessment. New York, NY: McGraw Hill; 2000:381-397.
7. Herr KA, Mobily PR, Kohout FJ, et al. Evaluation of the faces pain scale for use with the elderly. Clin J Pain. 1998;14:29-38.
8. Gagliese L, Melzack R. Age differences in the quality of chronic pain: a preliminary study. Pain Research and Management. 1997;2:157-162.
9. Bergh I, Sjostrom B, Oden A, Steen B. Assessing pain and pain relief in geriatric patients with non-pathological fractures with different rating scales. Aging (Milano). 2001;13(5):355-361.
10. Choiniere M, Melzack R, Rondeau J, Girard N, Paquin MJ. The pain of burns: characteristics and correlates. J Trauma. 1989;29(11):1531-1539.
11. Gallacher G, Rae CP, Kinsella J. Treatment of pain in severe burns. Am J Dermatol. 2000;1(6):329-335.
12. Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The faces pain scale for the assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990;41(2):139-150.
13. Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The faces pain scale revised: toward a common metric in pediatric pain measurement. Pain. 2001;93(2):173-183.
14. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409-414.
15. Grossberg GT, Sherman LK, Fine PG. Pain and behavioral disturbances in the cognitively impaired older adult: assessment and treatment issues. Annals of Long Term Care. 2000;8:22-24.
16. Cobbs E, et al. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 4th ed. Dubuque, Ia.: Kendall/Hunt Publishing;1999.
17. Ian Anderson Continuing Education Program in End-of-Life Care. Available at Accessed December 1, 2002.
18. American Medical Association. Pain Management: Resources for the Young Physician. Adapted from a report of the American Medical Association Young Physicians Section Governing Council, "Guidelines for Patients in Pain." Chicago, Ill.: AMA Department of Young Physician Services;2002.
19. Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the wound bed - debridement, bacterial balance and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.
20. Jacox A, Carr DB, Payne R, et al. Clinical Practice Guideline Number 9: Management of Cancer Pain. Rockville, Md. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service.Agency for Health Care Policy and Research; 1994: AHCPR Publication No. 94-0592.
21. Ferrell BR. Patient education and non-drug interventions. In: Ferrell BR, Ferrell BA, eds. Pain in the Elderly. Seattle, Wash: IASP Press; 1996:35-44.
22. Rochon PA, Fortin PR, Dear KB, et al. Reporting of age data in clinical trials of arthritis. Deficiencies and solutions. Arch Intern Med. 1993;153:243-248.
23. Ventsfridda V, Saita L, Ripamonti C, De Conno F. WHO guidelines for the use of analgesics in cancer pain. Int J Tissue React. 1985;7(1):93-96.
24. Dalton JA, Youngblood R. Clinical application of the World Health Organization analgesic ladder. Journal of Intravenous Nursing. 2000;23(2):118-124.
25. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain. 1999;83(3):389-400.
26. Boulton AJ. Treatment of symptomatic diabetic neuropathy. Diabetes Metab Res Rev. 2003;19(Suppl 1):S16-S21.
27. American College of Rheumatology Subcommittee on osteoarthritis guidelines. Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. Arthritis & Rheumatism. 2000;43(9):1905-1915.
28. MacLean CH. Quality indicators for the management of osteoarthritis in vulnerable elders. Ann Intern Med. 2001;135:711-721.
29. Graham DY, White RH, Moreland LW, et al. Duodenal and gastric ulcer prevention with misoprostol in arthritis patients taking NSAIDs. Misoprostol Study Group. Ann Intern Med. 1993;119:257-262.
30. Geba GP, Weaver AL, Polis AB, et al. Efficacy of rofecoxib, celecoxib, and acetaminophen in osteoarthritis of the knee: a randomized trial. The VACT Group (Vioxx, Acetaminophen, Celecoxib Trial). JAMA. 2002;287:64-71.
31. AGS Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 1998;46:635-651.
32. Melzack R. The tragedy of needless pain. Sci Am. 1990;262:27-33.
33. Fine PG. Pain and aging: overcoming barriers to treatment and role of transdermal opioid therapy. Clin Geriatr Med. 2000;8:28-36.
34. Portenoy RK. Chronic opioid therapy for persistent non-cancer pain: can we get past the bias? American Pain Society Bulletin. 1991;1-5.
35. Harden RN. Chronic opioid therapy: another reappraisal. American Pain Society Bulletin. 2002;12:1-12.
36. Canadian Pain Society task force. Use of opioid analgesics for the treatment of chronic non-cancer pain - a consensus statement and guidelines from the Canadian Pain Society. Pain Research and Management. 1998;3(4).
37. Persoli-Gudelj M. Treatment of pain with opiod analgesics and the role of TTS-fentanyl. Reumatizam. 2001; 48(2):29-37.
38. Fainsinger R, Schoeller T, Bruera E. Methadone in the management of cancer pain: a review. Pain. 1993;52:137-147.
39. Hanks G, Cherny N. Opioid analgesic therapy. In: Doyle D, Hanks GW, MacDonald N, eds. Oxford Textbook of Palliative Medicine, 2nd ed. Oxford, UK: Oxford University Press;1998:331-355.
40. Hollinworth H, Collier M. Nurses' views about pain and trauma at dressing changes: results of a national survey. Journal of Wound Care. 2000;9(8):369-373.
41. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. In: European Wound Management Association. Pain at Wound Dressing Changes: A Position Document. 2002:2-7.
42. Krasner, D. Managing pain from pressure ulcers. Am J Nurs. 1995;95(6):22, 24.
43. Ferrell BR, Ferrell BA, Ahn C, et al. Pain management for elderly patients with cancer at home. Cancer. 1994;74:2139-3432.
44. Ferrell BR, Rhiner M, Ferrell BA. Development and implementation of a pain education program. Cancer. 1993;72:3426-3432.
45. LeFort SM, Gray-Donald K, Rowat KM, et al. Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain. Pain. 1998;74:297-306.
46. Ferrell BA, Josephson KR, Pollan AM, et al. A randomized trial of walking versus physical methods for chronic pain management. Aging (Milano). 1997;9:99-105.
47. Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-S126.
48. Ferrell BR, Ferrell BA, eds. International Association for the study of Pain Task Force on Pain the Elderly. Pain in the Elderly. Seattle, Wash.: IASP Press;1966.
49. Gardner SE, Frantz RA, Troia C, Eastman S, MacDonal M, Buresh K, Healy D. A tool to assess clinical sign and symptoms of localized infection in chronic wounds: development and reliability. Ostomy/Wound Management. 2001;47(1):40-47.
50. Krasner D, Sibbald RG. Local aspects of diabetic foot ulcer care: assessment, dressings and topical agents. In: Levin ME, O'Neal DN, Bowker JH, eds. The Diabetic Foot, 6th ed. St. Louis, Mo.: Mosby-Yearbook;1999.
51. Bowler PG. Wound pathophysiology, infection and therapeutic options. Ann Med. 2002;34(6):419-427.
52. Bowler PG. Bacterial growth guideline: reassessing its clinical relevance in wound healing. Ostomy/Wound Management. 2003;49(1):44-53.
53. Wright JB, Lam K, Buret AG, Olson ME, Burrell RE. Early healing events in a porcine model of contaminated wounds: effects of nanocrystalline silver on matrix metalloprotineases, cell apoptosis and healing. Wound Repair Regen. 2002;10(3):141-151.
54. Winter GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. 1962. Journal of Wound Care. 1995;4(8):366-367.
55. Kannon GA, Garrett AB. Moist wound healing with occlusive dressings. A clinical review. Dermatol Surg. 1995;21(7):583-590.
56. Rovee DT. Evolution of wound dressings and their effects on the healing process. Clinica Materials. 1991;8(3-4):183-188.
57. Meuleneire F. Using a soft silicone-coated net dressing to manage skin tears. Journal of Wound Care. 2002;11(10):365-369.
58. Barnes HR. Wound care: fact and fiction about hydrocolloid dressings. J Gerontol Nurs. 1993;19(6):23-26.
59. Baxter H. A comparison of two hydrocolloid sheet dressings. Br J Community Nurs. 2000;5(11):572-577.
60. Eaglestein WH. Occlusive dressings. J Dermatol Surg Oncol. 1993;19(8):716-720.
61. Siegel DM. Contact sensitivity and recalcitrant wounds. Ostomy/Wound Management. 2000;46(1A Suppl):65S-74S.
62. Benbow M. Mixing and matching dressing products. Nursing Standard. 2000;23-29; 14(49):56-58,60,62.
63. Fletcher J. Exudate theory and the clinical management of exuding wounds. Professional Nurse. 2002;17(8):475-478.
64. Anderson I. Practical issues in the management of highly exuding wounds. Professional Nurse. 2002;18(3):145-148.
65. Cutting KF, White RJ. Avoidance and management of peri-wound maceration of the skin. Professional Nurse. 2002;18(1):33-36.
66. O'Brien M. Exploring methods of wound debridement. Br J Community Nurs. 2002;Dec:10-18.
67. Collier M, Hollingworth H. Pain and tissue trauma during dressing change. Nurs Stand. 2000;July;21-27;14(40):71-73.
68. Terrill PJ, Varughese G. A comparison of three primary non-adherent dressings applied to hand surgery wounds. Journal of Wound Care. 2000; 9(8):359-363.
69. Knauth A, Gordin M, McNelis W, Baumgrat S. semi-permeable polyurethane membrane as an artificial skin for the premature neonate. Pediatrics. 1989;83(6):945-950.
70. Ameen H, Moore K, Lawrence JC, Harding KG. Investigating the bacterial barrier properties of four contemporary wound dressings. Journal of Wound Care. 2000; 9(8):385-388.
71. Sprung P, Hou Z, Ladin DA. Hydrogels and hydrocolloids: an objective product comparison. Ostomy/Wound Management. 1998;44(1):36-46.
72. O'Dovovan DA, Mehdi SY, Eadie PA. The role of Mepitel silicone net dressings in the management of fingertip injuries in children. J Hand Surg (Br). 1999;24(6):727-730.
73. Limova M, Troyer-Caudle J. Controlled, randomized clinical trial of two hydrocolloid dressings in the management of venous insufficiency ulcers. Journal of Vascular Nursing. 2002;20(1):22-32.
74. Mertz PM, Marshall DA, Eaglstein WH. Occlusive wound dressings to prevent bacterial invasion and wound infection. J Am Acad Dermatol. 1985;12(4):662-668.
75. Fowler E, Papen JC. Evaluation of an alginate dressing for pressure ulcers. Decubitus. 1991;4(3):47-52.
76. Young T. Reaping the benefits of foam dressings. Community Nurse. 1998;4(5):47-48.
77. Campton-Johnston S, Wilson J. Infected wound management: advanced technologies, moisture-retentive dressings, and die-hard methods. Critical Care Nursing Quarterly. 2001;24(2):64-77.

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Enter the characters shown in the image.