Pressure Ulcer Pain: A Systematic Literature Review and ... · PDF filePressure Ulcer Pain: A...

16 OSTOMY WOUND MANAGEMENT FEBRUARY 2009 www.o-wm.com

FEATURE

Pain is an ever-present problem in patients with pressureulcers.1 As a protective physiologic mechanism, pain is de-

fined as an unpleasant sensory and emotional experience as-sociated with actual or potential tissue damage.2 Irrespectiveof a patient’s age or health status, pressure ulcer pain needs tobe assessed and treated because it has widespread physical andpsychosocial implications for the patient, family, and clinician.Zanca et al3 identified 32 grants as part of their examinationof pressure ulcer research funding; topics included pressureulcer assessment, prevention, and treatment; quality of carestudies that include pressure ulcers in their outcomes; or footpressure management in patients with diabetes mellitus. Onlyone focused on pain. Although pressure ulcer pain is under-represented among the funded projects, practitioners areasked to base pain assessment and treatment on research evi-dence. This paper summarizes research findings specific to

pressure ulcer pain in terms of pain assessment tools, medica-tions, wound care, and nutrition.

Pathophysiology of Pressure Ulcer PainPressure ulcer pain may be caused by tissue trauma from

sustained loads, inflammation, damaged nerve endings, infec-tion, dressing changes, debridement, operative procedures,and other treatments. The skin has more sensory nerves thanany other body organ.4 As the pressure ulcer cellular damageexpands, chemicals are released that irritate nociceptive nerveterminals. Nociceptive pain is an appropriate physiological re-sponse to a painful stimulus and involves acute or chronic in-flammation.5,6 The ulcer erodes through tissue planes anddestroys nerve terminals. As peripheral nerves regenerate, thenociceptive nerve terminals send out immature sprouts ofnerve tissue that may be hypersensitive to both noxious and

Pressure Ulcer Pain: A Systematic

Literature Review and National Pressure

Ulcer Advisory Panel White Paper Barbara Pieper, PhD, ACNS-BC, CWOCN, FAAN; Diane Langemo, PhD, RN, FAAN; and JanetCuddigan, PhD, RN, CWCN, CCCN

AbstractPain is an ever-present problem in patients with pressure ulcers. As an advocate for persons with pressure ulcers, the Na-

tional Pressure Ulcer Advisory Panel (NPUAP) is concerned about pain. To synthesize available pressure ulcer pain literature,

a systematic review was performed of English language literature, specific to human research, 1992 to April 2008, using

PubMed and the Cumulative Index in Nursing and Allied Health Literature. Fifteen relevant papers were found; they exam-

ined pain assessment tools, topical analgesia for pain management, and/or descriptions of persons with pressure ulcer

pain. Studies had small sample sizes and included only adults. The literature established that 1) pressure ulcers cause

pain; 2) pain assessment was typically found to be self-reported using different versions of the McGill Pain Questionnaire,

Faces Rating Scale, or Visual Analog Scale; 3) pain assessment instruments should be appropriate to patient cognitive

level and medical challenges; 4) in some cases, topical medications can ease pain and although information on systemic

medication is limited, pain medications have been found to negatively affect appetite; and 5) wound treatment is painful,

particularly dressing changes. Research gaps include the prevention and treatment of pressure ulcer pain, the impact of

pain on nutrition, and pressure ulcer pain considerations for special groups (eg, children, end-of-life patients, and bariatric

patients). The NPUAP presents this white paper as the current scientific know-ledge base on the topic. Research regarding

the multidimensional aspects of pressure ulcer pain is strongly recommended.

Key Words: pressure ulcers, pain, literature review, evidence

Index: Ostomy Wound Management 2009;55(2):16–31

Potential Conflicts of Interest: None

Dr. Pieper is a Professor/Nurse Practitioner, College of Nursing, Wayne State University, Detroit, MI. Dr. Langemo is a Distinguished Professor Emeritus and Adjunct

Professor College of Nursing, University of North Dakota, Grand Forks, ND. Dr. Cuddigan is Associate Professor, Chair, Adult Health and Illness Department,

College of Nursing, University of Nebraska Medical Center, Omaha, NE. Please address correspondence to: Barbara Pieper, PhD, ACNS-BC, CWOCN, FAAN,

College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit, MI 48202: email: [email protected].

16-31_OWM0209_Pieper:Layout 1 6/17/09 2:31 PM 6

FEBRUARY 2009 OSTOMY WOUND MANAGEMENT 17www.o-wm.com

PRESSURE ULCER PAIN WHITE PAPER

non-noxious stimuli. A heightened sensitivity to pain in thewound is primary hyperalgesia; a heightened sensitivity topain in the surrounding skin is secondary hyperalgesia.5,6 In-fection further irritates free nerve endings and may causepain.7 Pain, particularly acute pain, is also a stimulus to thestress response; thus, at the cellular level, hypoxia may developbecause of limited painful breathing and peripheral vasocon-striction and impede wound healing.8 Pain also may diminishappetite and decrease nutritional status.

Pain threshold and perception. Besides the physical causesand impact of pressure ulcer pain, pain threshold and percep-tion are important considerations. Pain threshold is theamount or degree of a noxious stimulus that leads a personto first interpret a sensation as painful. Pain perception is theactual awareness of the painful feeling or sensation; it may beacute or chronic. Pressure ulcer pain perception can be inten-sified by psychosocial factors, grief about the ulcer’s cause andpresence, and anger and fear in knowing its long-term treat-ment impact.

To enhance understanding and ultimately treatment ofpressure ulcer pain, this paper synthesizes the available rele-vant pressure ulcer pain literature. The National PressureUlcer Advisory Panel (NPUAP) presents this white paper asthe current scientific knowledge base on the topic.

Methodology Literature searches were performed using PubMed, a serv-

ice of the National Library of Medicine and the National In-stitutes of Health, and the Cumulative Index in Nursing andAllied Health Literature (CINAHL®) for the years 1992 to2008. Words/phrases used for the search included pressureulcer pain, bedsore pain, and decubitus ulcer pain. The searchwas limited to English language and human research. Fifteenpapers were identified — four addressed topical medicationtreatment and 11 presented varied aspects of pain measure-ment, pain treatment, and pain experiences. Papers aboutother types of wound pain and quality of life where pain wasone of many variables examined versus the critical variablewere not included in this review.

deLaat et al9 completed the last published systematic reviewabout pressure ulcer pain describing scientific evidence andmaking recommendations for practice; their review also in-cluded malodor and exudate. Six papers in deLaat’s review areincluded in the current review. Table 1 summarizes the pres-sure ulcer pain research obtained from this search in terms ofauthor/year, type of study, participants/sample, purpose, pro-tocol, and findings/main outcomes.

Results Pain assessment scales used in pressure ulcer pain re-

search. The single most reliable indicator of the existence andintensity of pain and any resultant distress is the patient’s self-report through the use of established reporting instruments.Three pain rating scales were used in pressure ulcer pain re-

search: the McGill Pain Questionnaire (MPQ), the Faces Rat-ing Scale (FRS), and the Visual Analog Scale (VAS).

Szor and Bourguignon10 used the MPQ because its de-scription of pain qualities and measure of pain intensityprovided a quantitative measure of pain. The MPQ con-tains the Pain Rating Index scale score and Present Pain In-tensity scale score. The most frequently used descriptors bypressure ulcer stage were: tender, hurting, sore (Stage II);burning, tender, hurting, sharp, sore, wretched (Stage III);and tender, hurting, smarting, penetrating, and throbbing(Stage IV). Although persons with Stage IV pressure ulcershad higher Pain Rating Index and Present Pain Intensityscores, they did not differ significantly from ratings by per-sons with Stage II or Stage III pressure ulcers. Roth et al11

used the MPQ and a singular pain intensity rating. No dif-ferences were found in pain ratings for Stage III and StageIV pressure ulcers. Persons with either Stage III or Stage IVpressure ulcers had significantly (P <0.05) more severe pain(ie, MPQ total and sensory and affective subscales) thanpersons with other wounds.

In Brazil, Quirino et al12 used a short version of the MPQ.Key descriptors used by persons with Stages I and Stage IIpressure ulcers included throbbing, sharp, burning, aching,and tugging. No study provided reliability or validity dataabout use of the MPQ for pressure ulcer pain.

Dallam et al13 used the FRS and the VAS. They found theVAS correlated with the FRS (r = .92) and the VAS correlatedwith pressure ulcer stage (r = .37). The intensity of pressureulcer pain correlated with generalized pain (r = .59). Usingdata from the Dallam study,13 Freeman et al14 reported statis-tical properties of the VAS and FRS for pressure ulcer pain.VAS variability significantly increased (P <0.01) with increas-ing FRS values. VAS and FRS were highly reliable for pain as-sessment in persons with diminished verbal and abstractthinking abilities and participants did not find them difficultto use. Freeman et al14 presented a mathematical translationof the FRS findings into VAS units. The VAS has since beenused in studies about pressure ulcer pain and medication use(information to follow).15,16

Key Points

• To enhance understanding and ultimately treatment of

pressure ulcer pain, the authors reviewed and synthe-

sized available relevant pressure ulcer pain literature.

• Even though the vast majority of pressure ulcer pa-

tients report pain, research on the topic is limited;

gaps in the current knowledge base are identified.

• Recommendations for practice include recognizing

that all pressure ulcers — especially treatments — are

painful, using a valid tool to assess pain levels, and

providing strategies to relieve the pain.

Ostomy Wound Management 2009;55(2):16–31

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FEATURE

Table

1: R

esearc

h a

bout

Pre

ssure

Ulc

er

Pain

in A

scendin

g O

rder

of Public

ation

Au

tho

r (Y

ea

r)

Jep

so

n (1

99

2)3

1

Dalla

m e

t al

(19

95

)13

Szo

r an

d

Bo

urg

uig

no

n

(19

99

)10

Typ

e o

f S

tud

y/M

eth

od

Descrip

tive (le

tter

to the

ed

itor)

Cro

ss-s

ectional

Cro

ss-s

ectional, c

om

par-

ative; tw

o p

ain

ratings

(rest and

dre

ssin

g

change) on the s

am

e

day

Part

icip

an

ts/S

am

ple

Siz

e

N=

17 (9 m

en a

nd

8 w

om

en);

age 5

4–91 y

ears

. A

ll con-

fined

to c

hair o

r b

ed

; 13 h

ad

ad

vanced

cancer. 3

0 p

res-

sure

sore

s, sta

ges 1

A to 5

of th

e U

K c

lassific

ation

N=

132 p

atients

(54 m

en a

nd

78 w

om

en) in

acute

care

;

age 2

4–100 y

ears

(M

=71.4

,

SD

=16.4

). 4

4 (33.3

%) ab

le

to resp

ond

to instr

um

ents

;

88 (66.7

%) not ab

le to re-

sp

ond

. 48%

had

a c

ognitiv

e

imp

airm

ent; 5

2%

were

cog-

nitiv

ely

inta

ct. E

thnic

/race

inclu

ded

: 66%

white, 22%

Afr

ican-A

merican, 11%

His

-

panic

, 2%

Asia

n. 68.9

%

had

a s

acra

l p

ressure

ulc

er

N=

32 p

atients

in a

cute

, ex-

tend

ed

, and

hom

e c

are

; age

47–95 y

ears

, M

+74.7

,

SD

=12.8

Fin

din

gs/M

ain

Ou

tco

mes

At 24 h

ours

, 29 o

f th

e 3

0 u

lcers

were

pain

-fre

e.

At 48 h

ours

, all

were

pain

fre

e. B

enzyd

am

ine

3%

cre

am

rate

d e

ffective a

s a

local agent to

relie

ve p

ressure

ulc

er

pain

41%

denie

d p

ressure

ulc

er

pain

; 59%

had

som

e typ

e o

f p

ain

. W

ith F

RS

, 68%

had

som

e

pain

(in

clu

ded

patients

with c

ognitiv

e im

pair-

ments

). O

nly

3 (2%

) p

ers

ons w

ere

giv

en a

nal-

gesic

s w

ith 4

hours

of th

e inte

rvie

w. VA

S

corr

ela

ted

with F

RS

(r=

.92). Inte

nsity o

f p

res-

sure

ulc

er

pain

corr

ela

ted

with g

enera

lized

pain

inte

nsity (r=

.59). L

ocaliz

ed

VA

S c

orr

e-

late

d w

ith m

axim

um

pre

ssure

ulc

er

sta

ge

(r=

.37). P

atients

on s

tatic a

ir rep

lacem

ent

matt

resses h

ad

sig

nific

antly less p

ain

than

those o

n o

ther

surf

aces (P

<0.0

1). T

hose

treate

d w

ith h

yd

rocollo

id d

ressin

gs h

ad

sig

-

nific

antly less p

ain

than o

ther

top

ical d

ress-

ings. N

o s

ignific

ant d

iffe

rence in p

ressure

ulc

er

pain

ratings b

etw

een p

ers

ons w

ho w

ere

cognitiv

ely

im

paired

and

those w

ho w

ere

not.

Sub

jects

receiv

ing a

nalg

esic

s for

pre

ssure

ulc

er

pain

rep

ort

ed

sig

nific

antly m

ore

pain

than those n

ot re

ceiv

ing a

nalg

esic

s; th

is w

as

als

o tru

e for

tranq

uili

zers

28 p

atients

had

pain

at d

ressin

g c

hange; 21

rate

d this

pain

as m

ild c

om

pare

d to 5

as e

x-

cru

cia

ting. 27 p

atients

exp

erienced

pain

at

rest; 4

had

no p

ressure

ulc

er

pain

. 12 re-

port

ed

pain

as c

ontinuous d

uring rest and

dre

ssin

g c

hange. O

nly

2 p

atients

had

re-

ceiv

ed

med

ication for

the p

ressure

ulc

er

pain

.

Pain

Rating Ind

ex a

nd

Pre

sent P

ain

Inte

nsity

were

not sig

nific

antly d

iffere

nt fo

r sta

ge o

f

ulc

er, rest vers

us d

ressin

g c

hange, fr

om

rest

to d

ressin

g c

hange a

cro

ss s

tages o

f ulc

ers

Pu

rpo

se

Exam

ine the e

ffective-

ness o

f aq

ueous-

based

cre

am

conta

inin

g 3

% b

enzy-

dam

ine for

pain

due to

pre

ssure

sore

s

Dete

rmin

e the p

erc

eiv

ed

inte

nsity a

nd

patt

ern

s

of p

ressure

ulc

er

pain

in h

osp

italiz

ed

patients

and

id

entify

rela

tions

betw

een p

ressure

ulc

er

pain

and

dep

ressio

n,

menta

l sta

tus, and

treatm

ent m

od

alit

ies

To c

om

pare

pain

exp

eri-

enced

by p

atients

with

Sta

ge II to

Sta

ge IV

pre

ssure

ulc

ers

at re

st

and

during d

ressin

g

change

Pro

toco

l

Ap

plie

d a

queous-b

ased

cre

am

conta

inin

g 3

%

benzyd

am

ine. C

overe

d

with s

em

i-p

erm

eab

le

film

and

tap

ed

in p

lace.

Patients

questioned

at

24 (n=

17) and

48 h

ours

(n=

14) re

gard

ing p

ain

re-

lief. P

ain

assessm

ent

scale

not p

resente

d

Sub

jects

evalu

ate

d w

ith

the F

ols

tein

Min

i-M

enta

l

Sta

te E

xam

ination,

Beck’s

Dep

ressio

n In-

vento

ry, Faces P

ain

Rat-

ing S

cale

(FR

S), a

nd

the

Vis

ual A

nalo

g S

cale

(VA

S)

Patients

rate

d p

ain

on the

McG

ill P

ain

Question-

naire



FEATURE

Gunes17 used the MPQ andthe Faces Rating Scale-Revised(FRS-R) in a study involving 47persons with Stage II to StageIV pressure ulcers. He reporteda statistically significant rela-tionship between the patient’spresent pain intensity and theFRS-R (r = .90); FRS-R meanpain intensity scores were ratedas moderate pain. He alsofound that MPQ completiontime was challenging for someparticipants and that pain in-tensity increased with pressureulcer stage. Only six patientsreceived pain medicationwithin 6 hours before comple-tion of the questionnaire andnone of the medications wasprescribed specifically for pres-sure ulcer pain.

Qualitative pressure ulcerpain studies1,18-20 were notfound to use a specific painscale — rather, participantswere asked to respond to open-ended questions about pain.Langemo et al’s study1 includedeight participants who de-scribed their pressure ulcer ex-perience; pain emerged as atheme. Fox18 used a semi-struc-tured interview in which fivepatients shared individual expe-riences of living with a pressureulcer. Pain was the dominant,recurring physical factor theme— an overwhelming aspect ofliving with a pressure ulcer.Hopkins et al19 used unstruc-tured interviews with eight per-sons to probe for themes ofliving with a pressure ulcer;endless pain was one of threethemes. In Rastinehad’s study,20

10 patients described what itwas like to have a painful pres-sure ulcer. Although samplesizes were generally small inqualitative studies, pain was acritical theme.

Because pressure ulcer painresearch is limited, it is important

Table

1: R

esearc

h a

bout

Pre

ssure

Ulc

er

Pain

in A

scendin

g O

rder

of Public

ation (continued)

Au

tho

r (Y

ea

r)

Lan

gem

o e

t al

(20

00

)1

Fre

em

an

et

al

(20

01

)14

Fo

x (2

00

2)1

8

Typ

e o

f S

tud

y/M

eth

od

Descrip

tive, q

ualit

ative,

phenom

enolo

gic

al

stu

dy

Second

ary

data

analy

sis

of cro

ss-s

ectional d

ata

from

Dalla

m e

t al 1999

Descrip

tive, p

henom

eno-

logic

al

Part

icip

an

ts/S

am

ple

Siz

e

N=

8; 4 w

ith c

urr

ent p

ressure

ulc

er

and

4 w

ith p

revio

us

pre

ssure

ulc

er. 7

men a

nd

1

wom

an; age 2

7–52 y

ears

. 4

had

sp

inal cord

inju

ry

N=

44 (see D

alla

m e

t al)

N=

5, 4 m

en a

nd

1 w

om

an;

age 3

1–64 y

ears

; d

ura

tion

of p

ressure

ulc

ers

4–36

month

s; p

art

icip

ants

liv

ed

in

the c

om

munity

Fin

din

gs/M

ain

Ou

tco

mes

7 them

es e

merg

ed

: p

erc

eiv

ed

etiolo

gy o

f th

e

pre

ssure

ulc

er;

life im

pact and

changes; p

sy-

cho-s

piritual im

pact; e

xtr

em

e p

ain

fuln

ess a

s-

socia

ted

with the p

ressure

ulc

er;

need

for

know

led

ge a

nd

und

ers

tand

ing; need

for

and

effect of num

ero

us, str

essfu

l tr

eatm

ents

; and

the g

rievin

g p

rocess. E

xtr

em

e p

ain

fuln

ess

associa

ted

with a

pre

ssure

ulc

er

was d

e-

scrib

ed

as feelin

g lik

e b

ein

g s

tab

bed

, gett

ing

a k

nife a

nd

dig

gin

g in there

, sitting o

n n

ee-

dle

s, b

urn

ed

, stingin

g. P

ain

was p

resent th

e

majo

rity

of tim

e a

nd

are

a h

urt

aft

er

the u

lcer

heale

d. A

nalg

esic

use inclu

ded

op

ioid

and

non-o

pio

id m

ed

ications

VA

S v

ariab

ility

sig

nific

antly incre

ased

with in-

cre

asin

g F

RS

valu

es. B

etw

een s

cale

s, th

e

VA

S a

nd

FR

S w

ere

hig

hly

relia

ble

for

pain

as-

sessm

ent in

pers

ons w

ith d

imin

ished

verb

al

and

ab

str

act th

inkin

g a

bili

ties

Thre

e m

ain

them

es w

ith s

ub

-them

es e

merg

ed

from

the inte

rvie

ws: p

hysic

al (p

ain

, exud

ate

s,

loss o

f in

dep

end

ence), p

sycholo

gic

al (e

mo-

tional fa

cto

rs, w

orr

y a

bout healin

g, re

lation-

ship

s, b

od

y im

age), a

nd

socia

l (s

ocia

l

isola

tion). P

ain

was a

dom

inant p

hysic

al fa

c-

tor

and

recurr

ing them

e thro

ughout th

e inte

r-

vie

w. P

ain

varied

in level of in

tensity a

nd

dis

turb

ed

sle

ep

. D

eep

ulc

ers

were

pain

ful

Pu

rpo

se

To e

xp

lore

the liv

ed

ex-

perience o

f havin

g a

pre

ssure

ulc

er

in o

rder

to d

ete

rmin

e the e

s-

sential str

uctu

re o

f th

e

exp

erience

To e

xam

ine s

tatistical

pro

pert

ies o

f th

e F

aces

Rating S

cale

(FR

S) and

describ

e the rela

tion-

ship

with the V

isual

Analo

gue S

cale

(VA

S)

To e

xp

lore

and

describ

e

exp

eriences o

f p

atients

livin

g w

ith a

pre

ssure

ulc

er

Pro

toc

ol

Part

icip

an

ts a

sked

to

describ

e t

he e

xp

eri-

en

ce o

f h

avin

g a

pre

s-

su

re u

lcer

Co

mp

ariso

n o

f p

atien

t

ratin

gs f

rom

FR

S a

nd

VA

S –

no

nlin

ear

least-

sq

uare

s r

eg

ressio

n w

ith

a G

au

ss-N

ew

ton

ite

ra-

tive p

roced

ure

Sem

i-str

uctu

red

in

ter-

vie

w



FEATURE

Table

1: R

esearc

h a

bout

Pre

ssure

Ulc

er

Pain

in A

scendin

g O

rder

of Public

ation (continued)

Au

tho

r (Y

ea

r)

Zep

pete

lla e

t al

(20

03

)15

Flo

ck (2

00

3)3

2

Qu

irin

o e

t al

(20

03

)12

Typ

e o

f S

tud

y/M

eth

od

Rand

om

ized

, d

oub

le-

blin

ded

, p

laceb

o-c

on-

trolle

d, cro

ssover

pilo

t

stu

dy

Rand

om

ized

, d

oub

le

blin

d, p

laceb

o-c

on-

trolle

d c

rossover

tria

l

Descrip

tive, cro

ss-s

ec-

tional

Part

icip

an

ts/S

am

ple

Siz

e

N=

5; 3 m

en a

nd

2 w

om

en;

age 6

2–87 y

ears

; hosp

ice

inp

atients

with a

dvanced

malig

nant d

isease; had

pain

ful p

ressure

ulc

er, n

ot

infe

cte

d, not covere

d w

ith

necro

tic tis

sue a

nd

suitab

le

for

once-d

aily

tre

atm

ent

with Intr

aS

ite*

gel. P

atients

had

sta

ble

analg

esic

regi-

mens. They w

ere

ab

le to

com

ple

te the V

AS

score

N=

13 h

osp

ice inp

atients

with

cancer;

3 m

en a

nd

10

wom

en; m

ean a

ge 7

6.5

years

. S

tage II (n

=8) or

Sta

ge III (n=

5) p

ressure

ul-

cers

. 7 p

atients

com

ple

ted

the s

tud

y

N=

20 fro

m 3

Bra

zili

an h

osp

i-

tals

; 15 m

en a

nd

5 w

om

en;

mean a

ge 5

7.2

5+

19.3

2

years

. 14 w

hite, 3 b

lack, 3

Asia

n. 16 h

ad

one p

ressure

ulc

er. 1

7 w

ere

sacra

l ulc

ers

.

Pre

ssure

ulc

er

sta

ges: 9

Sta

ge I; 8 S

tage II; 2

Sta

ge

III; a

nd

1 S

tage IV

Pers

ons

with p

ara

- or

tetr

ap

legia

and

para

- or

tetr

ap

are

sis

were

exclu

ded

Fin

din

gs/M

ain

Ou

tco

mes

All

had

low

er

VA

S s

core

s w

ith the m

orp

hin

e

treatm

ent. L

ocal or

syste

mic

ad

vers

e e

vents

were

not att

rib

ute

d to the m

orp

hin

e. A

uth

ors

conclu

ded

morp

hin

e a

pp

lied

top

ically

is a

n e

f-

fective m

eth

od

of p

rovid

ing local analg

esia

,

well

tole

rate

d b

y p

atients

and

not associa

ted

with s

yste

mic

ad

vers

e a

ffects

Pain

score

s im

pro

ved

sig

nific

antly (P

<0.0

03 a

nd

P<

0.0

05)at 1 a

nd

12 h

ours

, re

sp

ectively

, aft

er

dia

morp

hin

e g

el com

pare

d to b

aselin

e. In

tra-

Site g

el had

no e

ffect on p

ain

. M

ean p

ain

score

s w

ere

not giv

en. O

ne p

atient exp

erience

sym

pto

ms s

imila

r to

op

ioid

toxic

ity,

but th

ese

were

rela

ted

to h

er

fenta

nyl p

atc

h, not th

e g

el.

Although d

iam

orp

hin

e g

el is

pro

bab

ly s

afe

, a

larg

er

stu

dy is n

eed

ed

All

exp

erienced

pre

ssure

ulc

er

pain

. 80%

had

no

typ

ical t

ime p

att

ern

to the p

ain

; 55%

had

pain

at re

st and

45%

had

pain

with m

ovem

ent. 8

0%

had

consta

nt p

ain

. P

ain

did

not im

pair s

leep

(55%

), a

pp

etite

(75%

), o

r w

alk

ing (90%

). C

om

-

mon p

ain

descrip

tors

: 35%

burn

ing, 25%

thro

bb

ing, 25%

tuggin

g, 20%

sharp

. M

ean

pain

inte

nsity =

5.8

0±

2.9

3. S

ignific

ant associa

-

tions w

ere

found

betw

een p

ain

and

eth

nic

ity,

eth

nic

ity a

nd

ap

petite

, tim

e o

f d

ay a

nd

num

ber

of ulc

ers

, and

age a

nd

imp

aired

walk

ing (P

valu

e r

ange 0

.002 to 0

,034). 1

4 p

ers

ons took

nonste

roid

al a

nti-i

nflam

mato

ry p

ain

med

ication;

71.4

% rep

ort

ed

litt

le o

r no a

nalg

esic

effect. 1

3

describ

ed

rep

ositio

nin

g in

bed

, w

et d

ressin

gs,

and

massage a

s p

ain

managem

ent str

ate

gie

s

with 5

3.8

% rep

ort

ing s

atisfa

cto

ry o

utc

om

es

Pu

rpo

se

To e

xam

ine the a

nal-

gesic

effects

of m

or-

phin

e a

pp

lied

top

ically

to p

ain

ful

pre

ssure

ulc

ers

To d

ete

rmin

e the e

f-

fectiveness o

f d

i-

am

orp

hin

e g

el to

contr

ol p

ressure

ulc

er

pain

and

com

-

pare

it to

a p

laceb

o

To q

uantita

tively

and

qualit

atively

describ

e

pre

ssure

ulc

er

pain

Pro

toco

l

Part

icip

ants

were

tre

ate

d

for

2 d

ays w

ith m

or-

phin

e (m

orp

hin

e s

ulfate

inje

ction 1

0 m

g/m

i in

8 g

Intr

asite g

el)

or

pla

ceb

o

(wate

r fo

r in

jection in 1

mLin

8 g

Intr

asite g

el)

and

covere

d w

ith a

Tegad

erm

ad

ressin

g.

Aft

er

2 d

ays, th

ere

was

a 2

-day w

ashout aft

er

whic

h they c

rossed

over

to the o

ther

treatm

ent.

VA

S s

core

s w

ere

record

ed

tw

ice d

aily

3 d

ays Intr

aS

ite

bgel and

3 d

ays d

iam

orp

hin

e g

el

or

vic

e v

ers

a. A

pp

lied

once d

aily

. A

ll had

pre

s-

sure

-relie

vin

g c

ushio

ns

and

matt

resses. P

ain

was a

ssessed

befo

re

and

1 h

our

and

12 h

ours

aft

er

the g

el ap

plic

ation.

Pain

scoring: 0, no p

ain

;

1, m

ild; 2, m

od

era

te; 3,

severe

; 4, overw

helm

ing

Part

icip

ants

were

id

enti-

fied

by a

nurs

e, m

enta

l

sta

tus w

as a

ssessed

by

the M

enta

l E

valu

ation

Questionnaire, and

sig

ned

consent ob

-

tain

ed

. P

art

icip

ants

re-

sp

ond

ed

to a

dem

ogra

phic

question-

naire, p

ain

chara

cte

ristic

questions, and

the

McG

ill P

ain

Question-

naire. A

ll q

uestions w

ere

asked

befo

re top

ical

wound

care

. N

PU

AP

pre

ssure

ulc

er

sta

gin

g

was u

sed

a3M

Health C

are

, S

t. P

aul, M

Nb

Sm

ith &

Nep

hew

Larg

o, FL



FEATURE

Table

1: R

esearc

h a

bout

Pre

ssure

Ulc

er

Pain

in A

scendin

g O

rder

of Public

ation (continued)

Au

tho

r (Y

ea

r)

Ro

th e

t al

(20

04

)11

Pre

ntice

(20

04

)16

Ho

pkin

s e

t al

(20

06

)19

[su

m-

marized

by

Bale

et

al

(20

07

)52]

Typ

e o

f S

tud

y/M

eth

od

Cro

ss-s

ectional,

pro

sp

ective

Rand

om

ized

doub

le-

blin

ded

pla

ceb

o-c

on-

trolle

d trial

Heid

eggerian p

henom

e-

nolo

gy.

Inclu

sio

n c

rite

-

ria: >

65 y

ears

of age,

Gra

de 3

or

4 p

ressure

ulc

er

for

more

than a

month

, and

ab

le to g

ive

consent. E

xclu

sio

n c

ri-

teria: sp

inal cord

inju

ry

Part

icip

an

ts/S

am

ple

Siz

e

N=

69. A

ll m

en; m

ean a

ge 5

9

years

. 39 h

ad

Sta

ge III a

nd

Sta

ge IV

pre

ssure

ulc

ers

. 30

had

oth

er

wound

s (eg,

Sta

ge II p

ressure

ulc

ers

,

posto

pera

tive w

ound

s, ve-

nous s

tasis

ulc

ers

, or

dia

-

betic u

lcers

)

31 p

atients

ente

red

; 1 w

ith-

dre

w. A

ge r

ange 3

8–92

years

. 17 w

ere

in the b

enzy-

dam

ine h

yd

rochlo

rid

e g

roup

and

13 in the p

laceb

o

gro

up

. A

ll w

ere

in p

alli

ative

care

and

had

cancer

8 p

art

icip

ants

(7 fro

m U

nited

Kin

gd

om

and

1 fro

m B

el-

giu

m) fr

om

4 c

ente

rs a

nd

multip

le d

ata

colle

cto

rs

Fin

din

gs/M

ain

Ou

tco

mes

19 p

art

icip

ants

had

wound

pain

. A

tre

nd

for

a

gre

ate

r p

erc

enta

ge o

f p

atients

with S

tages III

and

Sta

ge IV

pre

ssure

ulc

ers

to e

xp

erience

wound

pain

com

pare

d to the o

ther

gro

up

(P=

.07). S

pin

al cord

inju

ry s

tatu

s d

id n

ot af-

fect p

ain

score

s. 28%

had

wound

pain

unre

-

late

d to d

ressin

g c

hange. W

ound

sta

ge w

as

positiv

ely

rela

ted

to p

ain

severity

. P

art

icip

ants

with S

tage II/IV

ulc

ers

had

more

severe

pain

on the M

PQ

tota

l, s

ensory

, and

affective

score

s than the o

ther

gro

up

. P

ain

cata

str

o-

phiz

ing w

as rela

ted

to p

ain

inte

nsity a

nd

to

hig

her

levels

of affective d

istr

ess a

nd

dep

res-

siv

e s

ym

pto

ms

The p

ain

score

s d

id n

ot d

iffe

r b

etw

een the tw

o

gro

up

s

Thre

e them

es w

ere

id

entified

: end

less p

ain

, re

-

str

icte

d life, and

cop

ing w

ith the p

ressure

ulc

er. E

nd

less p

ain

had

4 s

ub

them

es: con-

sta

nt p

resence, keep

ing s

till,

eq

uip

ment p

ain

,

and

tre

atm

ent p

ain

Pu

rpo

se

To c

om

pare

the u

tilit

y o

f

the s

ingula

r p

ain

inte

n-

sity r

ating s

cale

(N

u-

merical P

ain

Rating

Scale

[N

PR

S]) a

nd

a

multid

imensio

nal p

ain

questionnaire (M

cG

ill

Pain

Questionnaire

[MP

Q]). To

dete

rmin

e if

patients

with m

ore

se-

vere

wound

s rep

ort

more

severe

pain

in-

tensity.

To d

ete

rmin

e if

patients

with p

ain

dis

-

pla

y a

patt

ern

of p

sy-

cholo

gic

al d

istu

rbance

and

mala

dap

tive p

ain

cop

ing s

trate

gie

s

To c

om

pare

pain

red

uc-

tion fro

m top

ical b

en-

zyd

am

ine

hyd

rochlo

rid

e 3

%

cre

am

to

pla

ceb

o

To e

xp

lore

the e

xp

eri-

ence o

f old

er

peop

le

livin

g w

ith p

ressure

ul-

cers

Pro

toco

l

Part

icip

ants

were

as-

sessed

per

their w

ound

sta

tus b

y a

nurs

e a

nd

physic

ian. E

ach p

ers

on

was s

een a

maxim

um

of

6 v

isits a

nd

asked

ab

out

pain

. If w

ound

-rela

ted

pain

was p

resent, p

art

ic-

ipants

com

ple

ted

ad

di-

tional q

uestionnaires.

Oth

er

questionnaires in

the s

tud

y: B

rief S

ym

p-

tom

Invento

ry, C

ente

r

for

Ep

idem

iolo

gic

Stu

d-

ies D

ep

ressio

n S

cale

and

the c

ata

str

op

hiz

ing

scale

of th

e C

op

ing

Str

ate

gie

s Q

uestion-

naire. E

ach v

isit w

as

com

pensate

d ($10)

Each p

atient com

ple

ted

the 1

00 m

m V

AS

and

an

11-p

oin

t num

erical p

ain

score

at 24 h

ours

prior

to a

nd

im

med

iate

ly b

e-

fore

ap

plic

ation o

f th

e

cre

am

and

aft

er

at 2, 6,

12, and

24 h

ours

Unstr

uctu

red

inte

rvie

ws

and

use o

f p

rob

ing



FEATURE

to consider evaluating pressure ulcer painassessment options for special popula-tions of patients. Patients with cognitiveimpairment have been found to respondto pain assessment tools such as the FacesPain Scale and the Present Pain Intensitysubscale of the MPQ.21,22 Simple yes/noquestions (eg, Are you uncomfortable?Do you feel pain?) are used to assess pain.Family members or caregivers can reportexpressions/behaviors they recognize asindicators of pain. For critically ill inten-sive care patients, the Behavioral PainScale (BPS) assesses pain in terms of fa-cial expression, upper-limb movement,and ventilator compliance.23

Pressure ulcers in children need to beconsidered a source of pain.24 Pain as-sessment scales used with this popula-tion include the 0 to 10 pain rating scaleor the FACES.25 The Face, Legs, Activity,Cry, Consolability (FLACC) scale26 is abehavioral pain assessment instrumentinitially developed for scoring postoper-ative pain in young children. TheFLACC has been found to have high (r= .94) reported inter-rater reliability.27

The revised FLACC scale that includesspecific descriptors and identifies uniquebehaviors for individual children hasbeen found to have intra-class correla-tion coefficients ranging from 0.76 to0.90.28 Construct validity was demon-strated by decreasing FLACC scores fol-lowing analgesic administration.28 Forassessment of pain in neonates (ages 0 to6 months), the Crying; Requires O2 forSaturation >95%; Increasing vital signs;Expression; Sleepless (CRIES) scale hasbeen used effectively and has a high re-ported reliability.29,30

Medications for pressure ulcer paintreatment. Researchers have examinedthe use of topical medications for pres-sure ulcer pain treatment.15,16,31,32 Zep-petella’s,15 Prentice et al’s,16 and Flock’s32

studies used a randomized double-blindplacebo controlled design; in addition,Zeppetella’s15 and Flock’s32 studies in-cluded a crossover component. Jep-son’s31 descriptive study (N = 17) waspresented as a letter to the editor.

Zeppetella et al15 used the VAS to ex-amine the analgesic effect of 10 mg ofT

able

1: R

esearc

h a

bout

Pre

ssure

Ulc

er

Pain

in A

scendin

g O

rder

of Public

ation (continued)

Au

tho

r (Y

ea

r)

Rastin

eh

ad

(20

06

)20

Sp

ilsb

ury

et

al

(20

07

)44

Gu

nes (2

00

8)1

7

Typ

e o

f S

tud

y/M

eth

od

Heid

eggerian h

erm

eneu-

tic p

henom

enolo

gy,

qualit

ative

Qualit

ative s

em

i-str

uc-

ture

d inte

rvie

ws

Descrip

tive q

uantita

tive

and

qualit

ative

Part

icip

an

ts/S

am

ple

Siz

e

10 p

atients

, age 3

0 to 9

0

years

cap

ab

le o

f d

escrib

ing

their p

ain

exp

erience. 7 h

ad

Sta

ge II p

ressure

ulc

ers

; 2,

Sta

ge III; 1, S

tage IV. 8 u

l-

cers

on s

acra

l re

gio

n; 1,

heel; 1

, scap

ula

23 h

osp

italiz

ed

patients

; 5

men a

nd

18 w

om

en; ages

33–92 y

ears

(m

ed

ian 7

8

years

). M

ost com

mon p

res-

sure

ulc

er

locations: heel

and

sacru

m. P

ressure

ulc

er

gra

des w

ere

2 thro

ugh 5

47 h

osp

italiz

ed

patients

; 29

men a

nd

18 w

om

en; age 3

8

–72 y

ears

(m

ean 6

0.1

years

). P

atients

with s

en-

sory

moto

r d

eficie

ncie

s

were

exclu

ded

. P

ressure

ul-

cers

(n=

68) in

clu

ded

6

Sta

ge II, 3

2 S

tage III, and

9

Sta

ge IV. The m

ost com

mon

locations w

ere

sacru

m,

trochante

r, a

nd

heel

Fin

din

gs/M

ain

Ou

tco

mes

22 them

es a

nd

1 c

onstitu

tive p

att

ern

em

erg

ed

.

Pap

er

focuses o

n 2

them

es: P

ain

descrip

tors

and

failu

re o

f te

chnom

ed

icin

e to p

rovid

e

care

/com

fort

and

the c

onstitu

tive p

att

ern

;

pain

as e

xis

tence. P

ain

term

s w

ere

cate

go-

rized

as s

ensory

, evalu

ative, and

affective

Pain

was e

xp

erience b

y 2

1 p

ers

ons. P

ain

ranged

fro

m w

ors

e to little. P

ain

could

be

consta

nt or

varied

acro

ss the d

ay.

8 h

ad

pain

with d

ressin

g c

hange

Pre

ssure

ulc

er

pain

was rep

ort

ed

by 9

4.6

%

(n=

44) of th

e s

am

ple

. 13 w

ord

s w

ere

used

to

describ

e p

ressure

ulc

er

pain

; th

e n

um

ber

of

word

s incre

ased

as the p

ressure

ulc

er

sta

ge

incre

ased

. The m

ost com

mon term

was h

ot-

burn

ing. S

tage IV

pre

ssure

ulc

ers

had

the

hig

hest p

ain

inte

nsity.

The F

aces m

ean p

ain

inte

nsity w

as m

od

era

te p

ain

. 32 rep

ort

ed

dre

ssin

g c

hange a

ggra

vate

d the p

ain

Pu

rpo

se

To e

xp

lore

the q

ues-

tions, “W

hat is

it lik

e to

have a

pain

ful p

ressure

ulc

er?

”

To e

xp

lore

patients

’ p

er-

cep

tions a

nd

exp

eri-

ences o

f th

e im

pact of

a p

ressure

ulc

er

and

its

treatm

ent on h

ealth

and

qualit

y o

f lif

e

To d

escrib

e the q

uanti-

tative a

nd

qualit

ative

chara

cte

ristics o

f p

ain

rela

ted

to p

ressure

ul-

cers

Pro

toc

ol

Sem

i-str

uctu

red

in

ter-

vie

ws d

urin

g a

n 8

-

mo

nth

perio

d

Data

were

an

aly

zed

fo

r

them

es

Instr

um

en

ts in

clu

ded

pa-

tien

t d

em

og

rap

hic

s,

McG

ill P

ain

Qu

estio

n-

naire, an

d F

aces R

atin

g

Scale

-Revis

ed

. D

ata

were

an

aly

zed

with

de-

scrip

tive s

tatistics,

Fis

her

exact

test,

an

aly

sis

of

varian

ce,

an

d S

pearm

an

rank

co

rrela

tio

n c

oeff

icie

nt



FEATURE

morphine sulfate injection in 8 g Intrasite gel (Smith &Nephew) applied topically to painful pressure ulcers com-pared to water for injection 1 mL in 8 g Intrasite gel for fivepatients.15 Participants continued with their regularly sched-uled analgesia. They had lower (P <0.01) VAS scores with themorphine gel treatment (gel alone mean + standard deviation= 47 + 11 versus morphine gel = 15 + 11). Three patients re-ported localized discomfort with the gel alone but not withthe morphine gel. Systemic adverse effects were not noted withthe morphine gel.

Flock32 examined the effectiveness of diamorphine gel tocontrol pressure ulcer pain for 13 patients with grade 2 orgrade 3 pressure ulcers. Pain scores were rated as none (score0) to overwhelming (score 4). Among the seven patients whocompleted the study, pain score significantly improved 1 and12 hours after the diamorphine gel was applied; this was nottrue for the gel alone. New symptoms that patients developedduring the study (ie, skin irritation, pruritus, nausea/vomit-ing) were similar for the two treatments. One patient devel-oped symptoms similar to opioid toxicity when her fentanylpatch was increased; her symptoms resolved when the fentanyldose decreased.

Jepson31 reported that a aqueous-based cream containing3% benzydamine was effective within 24 hours in reducingpressure ulcer pain. The pain scale used in the study was notnamed. In a study with more controls, Prentice et al16 used theVAS and an 11-point numerical pain score to examine the ef-fect of topical benzydamine hydrochloride 3% cream as com-pared to a topical placebo cream on relief of pressure ulcerpain (N = 30). VAS and numerical pain scores decreased inboth groups. The reduction in pain was greater in the benzy-damine group but not significantly different. Comparing theVAS and numerical pain scale scores over time, Prentice16

noted the R-square values increased (ie, 66.4%, 74.2%, and94.5%), indicating participants learned how to use the variousscoring methods across the study.

The pressure ulcer pain literature included limited descrip-tive information about the use of systemic analgesics for thispain. Dallam et al13 reported three out of 132 participants(2.3%) were given pain medication for pressure ulcer painwithin 4 hours of pain measurement. Drugs used by these pa-tients that may have decreased pressure ulcer and other painincluded narcotics, nonsteroidal anti-inflammatory drugs(NSAIDs), tranquilizers, psychotropics, and sedatives. Szorand Bourguignon10 reported seven persons (21.8%) receivedpain medication within 6 hours before completing the painstudy; the medication was prescribed specifically for pressureulcer pain for only two of these persons. None of the sevenparticipants reported an absence of pain from the medication.

Studies on the use of systemic and/or local analgesics for pres-sure ulcer pain management in vulnerable patient groups (ie,neonates and children, patients with a history of substance abuse,morbidly obese/bariatric, minority groups, and at end of life)could not be found. This is an important concern. Children as

young as 3 years of age have been found to have painful memoriesof procedures.33 Minority groups have been found to be at riskfor inadequate pain control.34 Persons who have chronically usedopioids have been found to have a decreased tolerance for pain.35

In addition, clinicians may have misconceptions and value judg-ments about pain treatment in persons who used illicit drugs, es-pecially when the drugs were injected.36

Obese children and adults experience analgesic medicationadministration issues because excess body fat can alter drug ab-sorption37 — for example, drugs that are highly soluble in fat (eg,diazepam and carbamazepine) need the dose calculated using thepatient’s actual body weight, but drugs absorbed mainly in leantissue (eg, acetaminophen) should have the dose calculated usingthe patient’s ideal body weight.37 If an obese patient is to receivepain medication by intramuscular injection, standard intramus-cular needle length may not be sufficient to penetrate past theadipose tissue. Although the intravenous route is an option formore consistent administration of pain medication, vein accesscan be problematic in patients who are obese, as well as in personswho inject illicit drugs.

Langemo38 noted pressure ulcers are a concern for patientsreceiving palliative care but that little is known about woundsin these patients.38 For patients at the end of life, regular as-sessment for pain and use of therapies proven effective tomanage pain are recommended.39,40

Although research was not found about the impact of sys-temic analgesics on pressure ulcer pain, systemic analgesicsare a critical component in overall pain management and thusneed to be considered for chronic pressure ulcer pain. TheWorld Health Organization’s (WHO) Analgesic Dosing Lad-der41 frequently is used as a guide for systemic pain medicationmanagement. The WHO ladder includes many categories ofsystemic medications for pain management (eg, NSAIDS, opi-oids, and adjuvants) and encourages matching the analgesicto the patient’s level of pain. Using a 10-point scale where 10is the highest pain level, recommendations for analgesia in-clude mild opioids for scores 1 to 3, moderate opioids forscores 4 to 6, and strong opioids for scores 7 to 10.42 Sponta-neous or induced wound pain usually is treated with a sup-plemental systemic, rapid-acting opioid.43 Breakthrough painmedications should be administered with sufficient time totake effect, such as before a painful pressure ulcer treatment.A pain management specialist may help determine the mostappropriate medication protocols to minimize medicationside effects and toxicity maximize pain reduction/relief.

Wound care and pressure ulcer pain. Pressure ulcer pain as-sociated with treatment and/or wound care was reported in somestudies. Dallam et al13 noted patients whose ulcers were treatedwith hydrocolloid dressings as opposed to management withother topical dressings (P <0.02) had significantly less pain. Szorand Bourguignon10 reported 87.5% of participants had pain atdressing change. This pain ranged from mild (n = 21) to excru-ciating (n = 5). Pain did not differ at rest and at dressing changeacross the stages of ulcers. Spilsbury et al44 reported that eight out


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of 23 persons (34.8%) had pain with dressing change. Gunes17 reported that 32 out of47 patients (68.1%) stated dressing change aggravated pressure ulcer pain.

Although procedural pain may be addressed in literature regarding specific treat-ments, information on pressure ulcer pain research conducted during procedures/treat-ments was not found. Some authors presented findings about wound dressings andpain in general. For example, the Thunder Project II45 (N = 6,201) described pain re-lated to procedures commonly performed in critical care settings; one of the painfulprocedures was wound dressing change. Adolescents gave wound care the highest painintensity score and adults rated it the third most painful procedure (following turningand wound drain removal).

Choosing dressings that may mitigate the pain associated with dressing changes andadministering an analgesic before dressing changes have been found to be possiblestrategies for pain management.46 Pain rated as moderate (eg, 4 on a 1 to 10 scale)should prompt breaks during the dressing change, improved analgesia, and a reviewof current dressing protocols.6 The World Union of Wound Healing Societies,6 using amodified Delphi approach, developed a document that lists principles of best practicefor minimizing pain at wound dressing-related procedures. These principles include:1) be aware of current wound pain, 2) avoid unnecessary manipulation of the wound,3) explore patient-controlled techniques to minimize wound pain, 4) assess the skinand surrounding tissue for infection, necrosis, and the like, 5) consider the temperatureof the wound products, 6) avoid excessive pressure to the wound from dressing mate-rials, and 7) provide ongoing evaluation and manipulation of the management plan.

Nutrition and pressure ulcer pain. Specific research related to the impact ofpressure ulcer pain on nutrition could not be found. However, Bosley et al47 re-ported chronic pain was associated with self-reported appetite impairment in olderadults. The authors identified the need for research on the effect of pain reductionon appetite. Herr et al’s48 guideline about acute pain management in older adultsincludes a section about monitoring for nausea that may negatively impact nutri-tion. Guidelines49,50 on palliative care recommend minimizing dietary restrictions,offering small quantities of food at a time, and offering food more frequentlythroughout the day. Patients should select foods that match their appetite in termsof appearance, consistency, and aroma. The decision to use medications to stimu-late appetite should be made on an individual basis. Pain medication in and ofitself may affect appetite and taste.

ConclusionThe NPUAP is an advocacy organization that believes that all, or nearly all, pressure

ulcers cause pain. The NPUAP also believes it is crucial to increase the scientific knowl-edge base for pressure ulcer pain and disseminate this knowledge, particularly to thebedside clinician. Healthcare providers report that dressing change and wound treat-ment are among the most painful times for an individual with a pressure ulcer.

Pain assessment scales are available and have been used in research to measure pres-sure ulcer pain. Open-ended questions about pain also have identified the presence ofpain in persons with pressure ulcers. Clinicians should have a high index of suspicionof pressure ulcer pain in patients including those who cannot respond (eg, patientswith dementia, ischemia, and cancer). Irrespective of the pain assessment format used,patients with pressure ulcers need to be asked about their pain, using a structured toolor open-ended questions for assessment. Although pressure ulcer pain research has in-cluded Stage I through Stage IV to some degree, information on Stage I and Stage IVis more limited in published studies.

In general, research regarding pressure ulcer pain is limited. However, the results ofthis review underscore a number of perspicuous points. First, pressure ulcers causepain. Pressure ulcer pain was identified in both quantitative and qualitative studies.Second, pain levels in individuals with pressure ulcers — including neonates, children,



FEATURE

adults, and the elderly — must be routinely assessed. Third, anumber of pain assessment tools have been used in pressure ulcerpain research and include the MPQ, FRS, and VAS. Pressure ulcerpain assessment tools should match the cognitive level of the pa-tient and be appropriate for special groups, such as persons withcompromised mental competence, substance abuse, bariatricconcerns, spinal cord injury, and other neurological illness orend-of-life issues that can impair perception and pain reporting.Fourth, some research has noted the positive effects of topicalmedications for pressure ulcer pain. Research about the impactof systemic medications was not available. Fifth, wound caretreatments such as dressing changes can cause pain. Given thatdressings and their need for changing may cause pain, it is im-portant to consider dressings based on their comfort and fre-quency of change. Lastly, pain medication can affect appetite andtaste. The effect of pressure ulcer pain on nutritional status mustbe assessed. Pain medications should be administered on a sched-ule that maximizes the patient’s ability to eat and to be comfort-able during pressure ulcer treatment. The goal is to optimizefood/fluid intake and decrease the risk of nutritional problemssuch as weight loss and delayed healing.

Inadequate knowledge of pain is a barrier to its management.Although this review did not examine literature about pressureulcer pain education, pressure ulcer education needs to includecontent regarding pain assessment and management. This edu-cation should focus on the patient, family, caregivers, and clini-cians. Krasner51 noted clinicians need to become more sensitiveto pressure ulcer pain and respond to it. Continued pressure ulcerpain research is needed to identify the most effective methods ofassessing and managing pressure ulcer pain across the age con-tinuum and for special populations.

The NPUAP, in collaboration with the European PressureUlcer Advisory Panel, is developing pressure ulcer preven-tion and treatment guidelines with international application.These guidelines will be released at the NPUAP BiannualConference in Arlington, Virginia, February 27 – 28, 2009.Specific recommendations will be made for management ofpressure ulcer pain.

Further research is needed about pressure ulcer pain, includ-ing the degree and type of pain for each pressure ulcer stage. Re-search questions might include: Are certain topical analgesicsmore effective for pain in different stages of pressure ulcers or onpressure ulcers in different body locations? Are certain systemicanalgesics more effective for pain in different stages of pressureulcers? Are certain analgesics more effective for acute pressureulcer pain? What analgesic issues are relevant to chronic pressureulcer pain? Are certain analgesics, whether topical or systemic,more effective for different aged individuals with a pressureulcer? What are analgesic concerns and effectiveness issues forindividuals with a history of substance abuse or for individualsat the end of life? What is the most effective timing schedule ofanalgesic medications in relation to effective nutrition and fluidintake? How can pain scale ratings be used to guide medicationor dressing selection for a person with a pressure ulcer? What is

the best method to assess the presence of pressure ulcer pain andto assess if pressure ulcer pain is relieved in the non-cognitivelyintact individual or in children? Research also might considerpain management strategies including, but not limited to, med-ications and nonpharmacologic strategies such as physical andoccupational therapy, counseling, music, massage, and relaxation.The responses to these questions and concerns will help guideand improve care for patients with pressure ulcer pain. ■

AcknowledgmentThe author thanks members of the National Pressure Ulcer

Advisory Panel (NPUAP) Board of Directors 2007–2008 whoprovided critique of the manuscript.

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