Wound-related pain: assessment, prevention and holistic management

Wound-related pain is not a single symptom

The International Association for the Study of Pain (IASP) defines pain as a sensory and emotional experience associated with actual or potential tissue damage. Pain is therefore always what the patient describes, not what is visible in the wound.

In chronic wounds, pain arises from tissue damage, inflammation, infection, oedema, ischaemia or damage to the periwound skin, while repeated procedures add their own stimulus. Prolonged stimulation alters sensitivity, so that even light touch becomes painful.

Clinically, the most useful distinction is between background pain, which is present between procedures, and pain associated with a procedure or activity. These are accompanied by incident pain during movement and compression, and anticipatory pain: fear before a procedure that itself intensifies the sensation.

The most important guide is a change in the pain pattern: pain that has been stable for months and pain that suddenly worsens over hours or days are not the same clinical problem.

Pain assessment: a score from 0 to 10 is only the beginning

The European Wound Management Association (EWMA) review concludes that no single scale is suitable for every person and every chronic wound. Unidimensional tools measure intensity well, but do not reveal the pain mechanism or its impact on daily life.

The discussion can be guided by the OPQRST framework (onset, provocation and palliation, quality, radiation, severity and timing of pain), with mandatory questions about pain during dressing changes, night-time pain and what relieves it.

For someone who can communicate reliably, a numerical rating scale from 0 to 10 is practical for repeated measurements; verbal rating and visual analogue scales are equally valid alternatives. The key is to use the same tool at every review.

In chronic pain, its effect on the patient's life is equally important: whether it disrupts sleep, walking, personal hygiene, work, relationships, mood or the ability to follow treatment. Without this information, the effect of treatment cannot be assessed.

People with cognitive impairment require an adapted approach. EWMA cites the Pain Assessment in Advanced Dementia (PAINAD) scale, which is based on observation of panting, vocalisation, facial expression, body tension and consolability.

Differential diagnosis: what pain may reveal about the wound

The most important question is often not how much it hurts, but why. Measuring intensity without interpreting the cause creates an illusion of control.

Ischaemic pain can easily be mistaken for ‘usual wound pain’. In arterial disease, pain should be considered alongside skin temperature and colour, capillary refill, pulses and limb position; night-time rest pain requires expedited vascular assessment.

Infection and inflammation also increase pain. New or progressive pain, particularly with changes in exudate, local warmth, oedema, erythema or general condition, requires assessment of the depth and severity of infection rather than an automatic increase in analgesia.

A neuropathic component is more likely when there is burning, electric shock-like pain, prickling, numbness, altered sensation or pain triggered by light touch, which is common in diabetes and long-standing wounds.

The team's own procedures should also be reviewed: a solution that is too cold, aggressive cleansing, an adherent dressing, pulling on adhesive, maceration, dermatitis, an overtight bandage and incorrectly applied compression. These are causes the team can correct immediately.

Procedural pain: a successful dressing change begins before dressing removal

Pain during dressing changes is not an inevitable price of good wound care. If every procedure is very painful, identify where the pain occurs: during dressing removal, cleansing, removal of devitalised tissue or bandage application.

Dressing adherence is an important mechanism of procedural pain, and the available evidence supports atraumatic contact layers and removal techniques that do not damage the wound bed or periwound skin.

When painful debridement is planned, pain should be assessed in advance, not when the patient can no longer tolerate the procedure. Systematic reviews included by EWMA show that topical preparations may help some patients, but the evidence base remains heterogeneous, so the decision follows clinical assessment and a doctor's prescription.

The choice of debridement method affects procedural tolerance; EWMA describes evidence for methods in which pain was no greater than with comparator techniques. Procedural pain is therefore a legitimate criterion when selecting a method.

Before the procedure, explain what will happen, agree on a stop signal and allow enough time for the planned analgesia to take effect. The predictability of the procedure itself reduces pain.

Holistic management: treating the cause, the wound and the person

The first layer of treatment addresses aetiology. An ischaemic wound is not treated with analgesics without vascular assessment, a venous ulcer requires treatment of venous disease and appropriate compression, and a pressure ulcer requires pressure relief.

The second layer is local wound care: moisture balance, periwound skin protection and less unnecessary trauma. The dressing should retain exudate, avoid adhering to the wound bed and not require more frequent changes than necessary.

The third layer is a pharmacological strategy tailored to the pain mechanism, comorbidities and other medicines, and the expected duration of symptoms. Background and procedural pain are planned for separately, and the decision is made by a doctor.

The fourth layer is psychological. Expectation of pain, fear, catastrophising, anxiety and avoidance of activity intensify pain perception and make treatment more difficult to follow, so explanation and control over the procedure have a measurable effect.

The fifth layer is social and functional. Pain that disrupts sleep, isolates a person from others or prevents walking may be a greater problem than the wound area, and without family support and home care the plan is often not feasible.

Non-pharmacological measures that do not replace treatment of the cause

Non-pharmacological measures have a clear but limited role: they reduce tension and fear and improve procedural tolerance. They are most useful when agreed in advance and used alongside effective treatment of the underlying cause of the wound, rather than as a substitute for analgesia.

• Explanation of the steps and a pre-agreed signal for a pause.
• Comfortable positioning and limb support before starting.
• Short breaks rather than one long procedure.
• Directing attention through conversation during the procedure.
• Scheduling dressing changes for the time of day when pain is least.

Assessment and management algorithm

Monitoring outcomes and when to change the plan

A pain management plan is only as useful as its measurable effect. At every review, document pain intensity using the same scale, separately at rest and during dressing changes, together with several functional indicators: sleep, completion of dressing changes, walking and independence.

The aim of monitoring is not simply a lower score. If pain intensity has decreased but the person still cannot sleep or walk and avoids dressing changes, the plan is not successful. The layer that has not been fully implemented needs to be addressed, most often treatment of the cause or dressing selection.

Common mistakes in managing wound-related pain

• Pain is not assessed when the patient does not report it spontaneously.
• The scale is changed between reviews, making results non-comparable.
• A sudden increase in pain is managed solely by increasing the dose, without investigating the cause.
• Procedural pain is not documented, so dressing changes remain equally painful.
• The periwound skin, dressing and dressing-change technique are not checked.
• The neuropathic component is not recognised.
• Ischaemic pain is interpreted as ‘usual wound pain’, and vascular assessment is delayed.

When pain requires expedited assessment

Sudden-onset or rapidly increasing pain with coldness, pallor or cyanosis of the limb, and pain with signs of spreading infection and deterioration in general condition, should be assessed within 24 hours, or immediately if there is serious deterioration.

It is reasonable to reassess new persistent pain during compression, a sudden increase in pain during dressing changes, and new damage to or maceration of the periwound skin within approximately 72 hours.

What we know, and where the evidence remains insufficient

The 2024 EWMA document is based on a review of systematic reviews, supplemented by narrative searches and expert consensus, so the recommendations do not all carry the same level of certainty.

The most consistent message is not that there is one best analgesic method, but that assessment must be multidimensional, procedural pain must be recognised and planned for, and treatment of the underlying cause remains fundamental.

The evidence for psychological and complementary interventions specifically in wound care is weaker than in general pain medicine, so EWMA describes them as reasonable adjuncts rather than the foundation of the plan.

Razina dokaza·EWMA 2024 · heterogeneous evidence basethe document provides practical recommendations based on systematic reviews, additional literature and clinical expertise, but it is not a single pharmacological guideline, and not all recommendations carry the same level of certainty. The greatest gap remains high-quality prospective studies in which pain is the primary outcome and intensity, mechanism, function and quality of life are measured simultaneously.