A descriptive study of ulcer-related pain characteristics and management

Abstract

Background: Chronic leg ulcers are hard-to-heal wounds located below the knee and are increasingly prevalent in the Western population. Irrespective of pathology, chronic leg ulcers are associated with a negative impact on physical and psychosocial function and health status. While all chronic leg ulcers are presumed potentially painful, the prevalence of ulcer related pain is not clearly documented. A thorough description of pain characteristics, impact and management is not present in the available literature. Furthermore, little attention is paid to persistent pain at rest and between ulcer-related procedures such as ulcer-related background pain. Aim: This thesis aimed to explore the prevalence, characteristics, and management of ulcer-related background pain, as well as factors associated with moderate to severe ulcer-related pain. Materials and methods: The aims were addressed through a systematic review (Paper I) and a clinical study (Papers II and III). The systematic review was conducted to synthesize available data from both descriptive and effect studies, using the systematic review methodology guided by PRISMA. Random-effects meta-analyses—both overall and stratified by study design—were performed for pain prevalence and pain intensity. A univariable random-effects meta-regression analysis was performed to explore sources of heterogeneity. The clinical study used an exploratory cross-sectional design. Persons with chronic leg ulcers were recruited from two wound care clinics using the consecutive sampling method. Data was obtained through screening interviews, clinical examinations and questionnaires. In Paper II we analysed data from persons with chronic leg ulcers (N = 252) to establish the prevalence of ulcer-related background pain. Logistic regression with stepwise backwards elimination was used to identify factors associated with moderate to severe background pain. In Paper III descriptive analyses were used to explore characteristics (i.e., intensity, localization, temporal pattern, interference) of ulcer related background pain and pain management in participants who reported ulcer related background pain (N = 121). Main results: In the systematic review and meta-analyses we found a pooled prevalence of ulcer related background pain of 80 % (95% CI 65-92%) in persons with chronic venous leg ulcers. The pain intensity was moderate in average (NRS 4 [(95% CI 3.4-4.5]). The systematic review further confirmed the scarcity of descriptions of ulcer related pain characteristics. The clinical study confirmed that ulcer related background pain was common, with a prevalence of 64 % (95% CI 58-69%). Furthermore, in Paper II we found that older age, female gender, reduced sleep and diminished health status were associated with moderate to severe ulcer-related background pain. In the final model, reduced sleep quality increased the likelihood of having moderate to severe pain in persons with good health status while not in persons with diminished health status. In Paper III we provide a detailed and systematic description of the characteristics and management of ulcer-related background pain. The mean average background pain intensity was 4.5 (SD 2.56) (CI 95% 4.0-5.0), and more than 60% of those who reported ulcer-related background pain had moderate to severe pain (NRS > 4). The ulcer-related pain interfered with daily function to a moderate degree, and most participants reported intermittent pain. Further, the participants reported that pain management provided a mean pain relief of 45.9% (SD 33.9, range 0-100). Conclusion: Based on the findings from the three included papers, this thesis shows that ulcer-related background pain is a prevalent and intrusive problem that needs further attention, both in research and in clinical practice. Clinicians should pay attention to ulcer-related pain, and provide a thorough pain assessment in all persons reporting ulcer-related background pain. However, this is a single study, and the findings need further confirmation. Furthermore, future research should focus on development of strategies for assessment and management of ulcer-related pain.