Holistic management of wound-related pain: an overview of the evidence and recommendations for clinical practice

Abstract

Background Pain is a significant factor associated with wounds. Its presence can impact on every aspect of an individual, affecting their overall quality of life (QoL) including ability to function, as well as their social and psychological well-being. Holistic approaches that can help to address wound-related pain are vital to improve patient outcomes. Aim We aimed to review the evidence for the holistic management of wound-related pain in individuals with chronic wounds in order to provide recommendations for healthcare professionals in clinical practice. Method The L OVE platform was used for the search as wound and burn are in the same search category. L OVE collects systematic reviews retrieved from the systematic reviews database Epistemonikos and allocates them to specific L OVEs and questions. We conducted our search for reviews related to wounds and burns in November 2022. Retrieved titles and abstracts were exported into Rayyan. The search was organised within Rayyan according to the focus for each chapter to retrieve evidence on pain assessment, physical therapies, patient education, psychological approaches, and complementary and alternative approaches. A systematic approach was used by senior experts in wound and pain management for double-blind screening and application of inclusion criteria (chronic wounds and pain) to agree on articles for review. Sources related to acute wounds (including burn injuries) were excluded. The L OVE search was supplemented by narrative reviews of literature identified from the individual systematic reviews and handsearching of relevant sources. Results Thirty-eight systematic reviews and 27 additional articles were identified providing a total of 65 individual pieces of evidence. The number of reviews and articles included: pain assessment (n=25); physical therapies (n=8); patient education (n=12); psychological approaches (n=2); complementary and alternative approaches (n=18). The literature related to pain assessment highlighted that assessment of wound-related pain is complex and multidimensional. Healthcare providers must determine the most suitable assessment tool for their patients and in doing so consider an individual’s ability to respond to the assessment, as there is no one assessment tool to measure pain, as ‘one size does not fit all’. In terms of physical therapies, physical exercise is important, although the majority of evidence relates to individuals with venous leg ulcers (VLUs). In relation to management, clinicians need to recognize procedural-related pain, particularly in relation to debridement procedures. There may be a role for topical impregnated dressings and topical anaesthetics in this case. Equally it is important to manage moisture to prevent maceration and reduce the risk of pain from periwound skin irritation (dermatitis). For individuals with malignant fungating wounds (MFW) a combination of therapies to manage symptoms is recommended. Specific research related to patient education and wound-related pain is lacking, however areas that should be considered include aetiology of the wound and causes of pain, non-pharmacological and pharmacological methods for pain relief, methods for assessing pain relief, as well as impact of pain on QoL. Psychological approaches need to consider the factors associated with pain (attention, cognitions, emotions and emotion regulation and overt behaviour) in order to determine the most appropriate treatment strategy. Evidence to make recommendations for wound-related pain is sparse; however, there may be a role for social models of care and motivation enhancement programmes for individuals with leg ulcers. Additionally, aromatherapy and music therapy may also be helpful. Evidence for other chronic wounds is lacking. There is some evidence to support the role of honey for the management of wound-related pain, specifically the research indicates that the analgesic action may be related to its anti-inflammatory properties. Evidence for traditional Chinese medicine (TCM), plants, low-dose topical steroids and low level-laser therapy was very weak. Conclusion The experience of wound-related pain is complex and needs to take into consideration the psychological and social factors that can impact on an individual’s QoL to ensure a holistic approach. Equally the assessment of wound-related pain is complex and multidimensional. Healthcare providers must determine the most suitable assessment tool for their patients and in doing so consider an individual’s ability to respond to the assessment. Management of wound-related pain may require both non-pharmacological and pharmacological approaches and can include dressings and devices. A holistic strategy should also incorporate both education (patient and healthcare professional) and psychological approaches to improve patient outcomes. Our review has identified a lack of scientific resources on wound-related pain management to make clear recommendations for effective strategies. What is needed are further prospective studies of patients with wound-related pain and different types of non-healing wounds. Such research should be cognisant that a phenomenon as complex as pain must also be examined comprehensively. The phenomenon of pain has a high degree of subjective perception and individuals have different coping strategies, and healthcare professionals need to be mindful of this. The main determinants of wound-related pain management cannot solely be based on the wound symptomatology and the process of care (healing), but also need to consider the individuality of the patient and their current needs.