VOL: 103, ISSUE: 15, PAGE NO: 48
MA, BSc, DpSN, RGN, is tissue viability consultant, Eastbourne.Hampton, S. (2007) Chronic pain in wounds: a report on 11 case studies. Nursing Times; 103: 15, 48-50.
Hampton, S. (2007) Chronic pain in wounds: a report on 11 case studies. Nursing Times; 103: 15, 48-50.
Sylvie Hampton describes the effectiveness of an ibuprofen-impregnated dressing on wound pain.
This article describes the outcomes on 11 case studies of patients with painful wounds who were supplied with a new ibuprofen-impregnated dressing (Biatain-Ibu).
During the last 15 years, there has been an increased understanding of the processes associated with wound healing. Today there is a plethora of wound-treatment choices and wound care is an increasingly exciting and expanding field. However, wound management is often undertaken by health professionals who have not received sufficient training in this specialty (King, 2000) and this undoubtedly means that dressings are sometimes used inappropriately (Bux and Malhi, 1996). There are also a wide variety of available dressings and it can be a difficult task to select the most appropriate for any particular wound. This difficulty with choice becomes even harder when the patient is experiencing pain as some dressings can actually increase pain (Hampton and Collins, 2003).
Each wound dressing has been specifically designed for a purpose with the primary function being to prepare the wound bed for healing; this requires knowledge of the physiological responses that occur in a wound with each different dressing type. However, although wound pain remains an integral part of wound assessment, pain control is still neglected. Six out of 10 patients with chronic wounds experience pain (Hofman et al, 1997) and these patients often report pain as dominant in their lives (Krasner, 1998). Therefore, pain related to the wound should be handled as one of the main priorities in chronic wound management together with addressing the cause of that pain (Hampton and Collins, 2003; Dallam et al, 1995; Phillips et al, 1994).
A study of wounds identified that although a quarter of patients reported pain associated with their wounds, none received analgesia before dressing changes (Bux and Malhi, 1996). Chronic wound pain is distressing and influences the patient's ability to function (Reddy et al, 2003); incorrect diagnoses and inexperience may lead to selecting dressings that have the potential to increase pain within the wound bed.
The reasons for wound pain are shown in Box 1.
Patients can experience soreness, burning, itching, stinging, throbbing and many more types of pain associated with wounds. The type of pain experienced can indicate the source of the pain and provide a guide for how that pain can be reduced. The two types of pain examined here are nociceptive pain and neuropathic pain.
Nociceptive pain Nociceptive pain has been defined by Woolf (2004) as pain induced in the nociceptor and nociceptive pathways by a noxious stimulus. Prostaglandins act as chemical messengers and work within the cells where they are synthesised and will excite and sensitise nociceptors. NSAIDs will block the prostaglandins biosynthesis, which reduces the sensitisation of nociceptors and therefore has a major effect on pain at this level (Fracasso et al, 2002).
The experience of nociceptive pain is one of soreness or burning. This is likely to be relieved by a soothing wet dressing such as a hydrogel or an application of a topical analgesia such as an NSAID that can be delivered in a dressing.
Neuropathic pain Neuropathic pain has been defined as pain initiated or caused by damage to or dysfunction of neurons in the peripheral or central nervous system (Schaible and Richter, 2004). The pain felt with this type is likely to be stabbing, sharp, continuous, burning, throbbing, fiery, shock-like or sharp.
In order to address the issue of pain during dressing wear time, a new dressing has been introduced to the wound care market. The dressing is a combination of a highly absorbent foam and an active ingredient of ibuprofen (Jørgensen et al, 2006). On contact with wound fluid, ibuprofen is released onto the wound at 0.5mg of ibuprofen per cm2, which is equal to 50mg (a quarter of a standard tablet), bound into a 10cm by 10cm foam dressing. This is significantly lower than the usual topical dose or the recommended oral dose for mild to moderate pain and has no systemic effects (Jørgensen et al, 2006).
Three studies demonstrated a reduction in pain when this absorbent wound dressing with ibuprofen was applied with nine out of 10 patients reporting improved mobility, sleep and mood during the studies (Flanagan et al, 2006; Jørgensen et al, 2006; Sibbald et al, 2006).
Jørgensen et al (2006) tested the ibuprofen impregnated dressing for pain reduction safety and efficacy on 12 patients in a single blinded cross-over study against a placebo. Flanagan et al (2006) carried out a prospective case series examining 10 patients with painful chronic venous leg ulcers who were treated for six dressing changes with the dressing and appropriate compression bandaging. The aim of the case series was to profile the characteristics and experience of these individuals. Endpoints of the study were changes in wound pain intensity, relative ulcer area and health-related quality of life. An investigation of pain reduction efficacy and the impact on quality of life of the dressing was carried out by Sibbald et al (2006). The dressing was tested by 12 patients and compared with local best practice (12 patients). Pain and moist wound healing parameters were also assessed.
The author was invited to review the potential of the ibuprofen-impregnated dressing when used in 'real-life' wounds. Real-life wounds can be used to describe wound types that are common to community nurses in their day-to-day work and are therefore extremely variable. This is different to a structured research approach, such as randomised controlled trials, where inclusion and exclusion criteria ensure the research wounds are closely similar and are not representative of the mix of wounds generally found by community nurses. These real-life wounds will often be intractable and represent all wound types such as venous and arterial leg ulcers and pressure ulcers.
In order to assess the potential for reducing pain in wounds, a series of case studies were undertaken in 11 patients who were experiencing pain.
Wound pain assessment is based on characteristics of pain including location, duration, intensity, description, association with management procedures and impact on quality of life and activities of daily living. Pain can be assessed by observing patient behaviour, such as the amount of time spent resting, medication use and verbal/motor pain behaviour; these methods may be particularly useful when dealing with those unable to communicate effectively.
The challenge for health professionals is to convert complex, dynamic events experienced by individuals into simple numeric pain scales such as a visual analogue scale (VAS - a 10-cm horizontal line with indicators of severity such as 'no pain' at one end and 'worst pain possible' at the other). This was the scale used in this series of case studies.
Methodology The purpose of the study was to investigate pain reduction efficacy and the impact on quality of life of the ibuprofen-impregnated dressing.
Eleven patients were assessed for wound pain and the level of pain was established through the VAS. Patients were asked to complete a daily pain diary over a 10-day period and, where possible, photographs were taken.
Results The age range of the patients involved in the case studies was 45-87 years with an average age of 74. The types of wounds are shown in Box 2.
The lowest score on the first day was 1 and the highest score was 10, with all patients providing an overall score of 75. This overall score for all 11 patients reduced to 29 on the final day. The level of pain reduced by 23% overall in the 11 patients following the first application and reduced by 61% at the final application of the dressing.
For some patients, the pain was reduced completely; for others there was some pain relief. One patient had an increase in pain due to inflammation over the peri-wound area although this was common to her and occurred regularly. The wound recovered very quickly.
The greatest success was in a female patient who suffered from a pyoderma gangrenosum wound. Her pain reduced from 8 to 0 and remained at that level with continued use of the dressing. The only alteration in this level of pain is when the dressing has been in place for three days and requires changing.
Another female patient had a small wound on a surgical site following an above-knee amputation. She had continuous pain in the wound, which she said made her life miserable. Application of the dressing reduced her pain completely and gave her a quality of life that had not existed prior to the case study.
Although for the majority of the patients pain was reduced almost immediately after application, full pain relief was not always immediate and it could take up to 24 hours before the VAS score was considerably reduced.
Discussion This was a series of case studies reviewing 11 patients with painful wounds and their experience with the ibuprofen-impregnated dressing over a 10-day period. Due to the small number of patients and short period of the trial, this article will not attempt to claim statistical significance in pain reduction. However, many patients experienced pain relief and, given that pain is largely ignored in wound care, this dressing is a positive step forward.
The dressing did not help relieve pain for all patients, although this could have been predicted as pain has a different cause in each person and is unique to that individual. Ischaemic pain is often not in the wound itself but in the area surrounding the wound or distal to the wound in the foot. This pain may not be aided by a topical application of NSAIDs and may require oral drugs such as tramadol (Hollingshead et al, 2007), gabapentin (Wiffen et al, 2007) or amitriptyline (Saarto and Wiffen, 2007). Nevertheless, the patients who experienced pain relief from this dressing had suffered pain for months and were grateful for the opportunity to trial it. Those patients were provided with a stock of dressings so that they could continue using them following completion of the case study.
The overall results of the study supported the three research studies reported near the beginning of this article. These all found a reduction in pain when the ibuprofen-impregnated dressing was applied.
At present, the only route open to pain control is through knowledgeable and thoughtful assessment and appropriate use of dressings. As pain is often a patient's prime concern, it is essential that health professionals address the treatment of the cause and focus on patients' concerns. The ibuprofen-impregnated dressing will help to provide a tool to enable nurses to deal with pain in the provision of wound care.
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