More than half of older adults with chronic venous leg ulcers report pain (Nemeth, Harrison, Graham, & Burke, 2003) which may be experienced for years or decades of ulceration. Both nociceptive and neuropathic pain have been documented, although prevalence of each is largely unknown as few studies differentiate the type of pain (Travener, Closs & Briggs, 2011). Importantly, significant levels of pain are often present, for example, over 50% of patients with venous leg ulcers in one study reported moderate to severe levels of pain on admission to the study (Edwards, Finlayson, Skerman, et al. 2014). Pain leads to inflammatory mediator release, which is suggested to interrupt the normal phases of wound healing (Widgerow & Kalaria, 2012). In addition, pain has been reported as a reason for poor adherence to compression therapy (Miller et al., 2011) – the primary evidence-based treatment for venous leg ulcers (O'Meara, Cullum, Nelson, & Dumville, 2012). The purpose of this study was to determine the relationships between pain, evidence-based treatment, and clinical outcomes in a sample of adults with venous leg ulcers.
Methods:
Secondary analysis was undertaken of data on demographic, health, psychosocial, clinical, pain and compression therapy collected for five longitudinal, observational studies of patients with venous leg ulcers (total n=540). Participants were followed for 24 weeks and data collected weekly on level of compression therapy, pain management and progress in healing. Logistic regression was utilised to identify significant relationships between pain, level of compression therapy, and ulcer healing, while controlling for potential confounders.
Results:
On a Numeric Pain Rating scale from 0–10, the mean pain score on enrolment to the studies was 3.06 (SD 2.96). Over a quarter (26%, n=140) of participants reported moderate pain (score 4–6), while 16% (n=86) reported severe pain (scores >7). There was no association between levels of compression therapy applied and pain scores at enrolment, however, in the following 12 weeks, participants who scored severe levels of pain at enrolment were significantly less likely to remain treated with high level (>30mmHg at the ankle) compression therapy (chi2 36.3, p=0.001). Higher pain levels were associated with younger age (p<0.001), female gender (p=0.005), depressive symptoms (p=0.026), decreased quality of life (p<0.001), and larger ulcer area (p<0.001). Logistic regression analysis found pain score at enrolment was negatively associated with the likelihood of healing after 24 weeks of care (OR 0.90, 95% CI 0.83–0.98, p=0.013); while treatment with high level compression therapy was positively related to the likelihood of healing after 24 weeks of care (OR 2.23, 95% CI 1.38–3.62, p=0.001).
Conclusion:
A large proportion of patients with venous leg ulcers experience moderate to high levels of pain, which is related to cessation of the primary evidence-based treatment for venous leg ulcers, compression therapy. Failure to treat with high compression therapy is significantly related to delayed healing, and interestingly, even when controlling for compression level, higher pain levels are also significantly associated with delayed healing. These findings indicate a need to implement effective pain management to promote healing and implementation of evidence-based practice.
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