Clinical correlates of pain in adults with hard-to-heal leg ulcers: a cross-sectional study
Abstract
Objective:
Pain is a complex symptom associated with hard-to-heal (chronic) leg ulcers that is often poorly managed. The objective of this study was to gain greater understanding by investigating relationships between physical and psychosocial factors, and pain severity in adults with hard-to-heal leg ulcers.
Method:
A secondary analysis of data collected for a longitudinal, observational study of adults with hard-to-heal leg ulcers was undertaken. Data were collected over a 24-week period, including variables relating to sociodemographics, clinical variables, medical status, health, ulcer and vascular histories, and psychosocial measures. Multiple linear regression modelling was used to determine the independent influences of these variables on pain severity, as measured with a Numerical Rating Scale (NRS).
Results:
Of 142 participants who were recruited, 109 met the inclusion criteria for this study, of whom: 43.1% had venous ulcers; 41.3% had mixed ulcers; 7.3% had arterial ulcers; and 8.3% had ulcers from some other cause. The final model explained 37% (adjusted r2=0.370) of the variation in the pain NRS scores. Controlling for analgesic use, salbutamol use (p=0.005), clinical signs of infection (p=0.027) and ulcer severity (p=0.001) were significantly associated with increased pain, while the presence of diabetes (p=0.007) was significantly associated with a decrease in pain.
Conclusion:
Pain is a highly complex and pervasive symptom associated with hard-to-heal leg ulcers. Novel variables were identified as being associated with pain in this population. The model also included wound type as a variable; however, despite being significantly correlated to pain at the bivariate level of analysis, in the final model, the variable did not reach significance. Of the variables included in the model, salbutamol use was the second most significant. This is a unique finding that, to the authors' knowledge, has not been previously reported or studied. Further research is required to better understand these findings and pain in general.
Hard-to-heal (chronic) leg ulcers have negative implications for an individual's physical, psychological and social functioning.1,2,3 In a systematic review by Phillips et al.,3 it was identified that pain, exudate levels and odour were significant factors impacting the physical, psychological and social functioning of adults with hard-to-heal venous leg ulcers (VLUs), leading to reductions in quality of life (QoL) as well as mood, sleep and mobility.3 In a systematic review of 23 studies by Green et al.,4 it was found that hard-to-heal VLUs negatively impacted all aspects of daily life and that pain was a dominant theme in all studies.4
Pain is a complex and pervasive issue. When observed in cases where pain is not limited to its functional purpose of protection, it can severely affect an individual's QoL.2,5,6 Despite pain having a large impact in this regard, it is often poorly managed in adults with hard-to-heal leg ulcers,2 as exemplified by the work of Hamer et al.,7 who found that 37.5% of participants with hard-to-heal leg ulcers thought that pain was the worst aspect of the condition. In a study by Edwards et al.,8 it was found that 74% of the 318 participants experienced pain related to a hard-to-heal leg ulcer, with 56% of participants experiencing pain that was rated moderate-to-severe. In a more recent study of participants with hard-to-heal VLUs by Leren et al.,9 it was identified that at least 80% of participants had a background pain intensity of 4 (on a scale of 0–10).
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