Meeting the challenges of wound-associated pain: anticipatory pain, anxiety, stress, and wound healing.

P ain is an unpleasant physical and emotional experience that plays a key role in the lives of people with chronic wounds. It is well documented that the majority of patients with chronic wounds suffer from moderate to severe pain for a protracted period of time with frequent exacerbations. Although pain often is associated with conditions intrinsic to underlying etiologies (eg, acute lipodermatosclerosis in venous leg ulcers, Charcot changes with diabetic foot ulcers), trauma (pressure, shear, and friction), chemical irritation, infection, or inflammation, spontaneous pain may occur due to sensitization of nerve fibers. In studies conducted during dressing changes, patients describe the most excruciating pain at dressing removal as aggressive adhesives are peeled away from fragile and damaged periwound skin. Increasing evidence also validates pain with wound cleansing, especially when abrasive materials or forceps are used to remove debris from the wound bed. To raise awareness and promote a systemic approach to managing pain, Woo and Sibbald developed a wound-associated pain (WAP) model that highlights three key components: the wound, the cause, and the patient (see Figure 1). First, the underlying cause of the wound-associated pain must be treated. Second, local wound care issues that may exacerbate woundassociated pain must be addressed. These include tissue trauma (dressing removal and wound cleansing); moisture balance (too much moisture can cause skin maceration and erosion while too little moisture dries out the dressing that then tends to adhere to wound bed); infection/inflammation (increased pain is a warning sign for potential deep wound infection); and patient-centered concerns (eg, anxiety, depression, anticipation of pain). Meeting the Challenges of Wound-associated Pain: Anticipatory Pain, Anxiety, Stress, and Wound Healing