Compression therapy, autonomic nervous system, and heart rate variability: A narrative review and our preliminary personal experience

Aims

To highlight the relationship among compression therapy (CT), the autonomic nervous system (ANS) (parasympathetic and sympathetic system), and the heart rate variability (HRV) analysis.

Background

Beyond the typical analgesic and anti-inflammatory effects of CT in patients affected by venous and/or lymphatic diseases, some literature about CT influence on wellbeing has been published as well. More specifically, CT influence on the ANS has been elucidated mostly through HRV application, providing useful quali-quantitative data for scientific and clinical purposes.

Material and Methods

A literature search was performed through several web-based search engines to investigate the available evidence concerning the possible influence of CT on the ANS and on psychoneuroendocrineimmunology. Moreover, we examined literature data regarding HRV use in the assessment of CT. Lastly, a preliminary cross-over study was performed on 10 patients affected by phlebolymphedema of the lower limbs, undergoing CT with 18–21 mmHg stockings for 10 h and investigated by means of HRV.

Results

A CT-based increase of the anti-inflammatory activity of the parasympathetic (vagal) system has been elucidated in most scientific literature. Similarly, CT application has generally resulted in an improvement of HRV, which indicates a beneficial influence on the ANS. In our preliminary experience with compression stockings and HRV, two parasympathetic-based parameters improved by 22.8% and 68.0% after 10 h, whereas they decreased in the same subjects without stockings by 2.7% and 8.2%, during normal breathing. The remaining HRV parameters did not show relevant variations, especially during diaphragmatic breathing.

Conclusions

From literature data and based on our very preliminary experience, it is possible to deduce that CT exerts different effects on the psychobiological parameters of the individual, overall improving HRV and parasympathetic activity. Incorporating both HRV/ANS assessment in phlebolymphology and the beneficial neural action of CT in health care may represent viable options in the future biomedical science.

Leg Ulcers and Pain: A Review

Leg ulcers are a common health problem. Ulcers of any etiology including venous ulcers may be very painful, but until recently, health professionals have not been good at recognizing or managing this type of pain. It is important to clarify the type, severity, and frequency of pain and to anticipate pain at dressing changes. The measurement of pain by the use of pain scales is very useful, particularly in assessing the efficacy of an intervention. Neuropathic pain and unusually painful ulcerations are discussed in this article.

Quality of Life in Venous Ulceration: A Randomized Trial of Two Bandage Systems

Objective:

To evaluate health-related quality of life (HRQoL) in a prospective randomised trial of patients suffering from venous ulceration, comparing the original four-layer bandage system with a new four-layer system (Profore).

Design:

Randomised prospective parallel groups trial.

Setting:

Community leg ulcer clinics within two trusts in England.

Participants:

Patients newly presenting for treatment suffering from chronic leg ulceration, with ankle–brachial pressure index (ABPI) >0.8.

Methods:

Patients entering the trial were asked to complete the Nottingham Health Profile (NHP) at entry and after 12 and 24 weeks of treatment. Principal analysis was the comparison of final NHP scores analysed by ANOVA with baseline scores entered as a covariate.

Results:

In all, 231 of 232 patients who entered the trial completed the initial questionnaire, with 208 patients completing at least one follow-up questionnaire. Improvements were noted for all scores after 24 weeks, which were significantly greater in the 167 patients whose ulcers had healed compared with the 41 whose ulcers remained unhealed for the domains of Sleep (mean difference [ d] = 10.5, 95% CI 2.9 to 18.1, p = 0.007) and Bodily Pain ( d = 8.9, 95% CI 1.3 to 16.5, p = 0.023), with a large difference for Physical Mobility ( d = 5.0) which failed to achieve statistical significance (95% CI −0.5 to 10.6, p = 0.07) following adjustment for the baseline scores. There were similar mean scores between the 99 patients treated with the original bandage system and 109 treated with Profore for all domains of the NHP, the largest adjusted difference favouring Profore for Energy ( d = 3.7, 95% CI −3.8 to 11.2, p = 034).

Conclusions:

Patients suffering from leg ulceration show improvements in perceived health following effective ulcer management. The two bandage systems achieved similar improvements in perceived health over 24 weeks.

Deficiencies in Leg Ulcer Care: A National Survey in Scotland

Objective:

To identify what specialist expertise and services are currently available, in Scotland, to support general practitioners (GPs) and community nurses in the management of leg ulcer patients and the perceived need for the improvement of the service.

Design:

Postal questionnaires to randomly selected samples of GPs and community nurses.

Setting:

All 15 Scottish Health Board areas.

Subjects:

Six hundred and seventy-three GPs and 441 community nurses were questioned.

Results:

Five hundred and twelve (76%) GPs replied. Barely half, 285 (56%), expressed satisfaction with the service and only 155 (30%) had access to a recognized leg ulcer specialist. GPs who had access to a specialist expressed a greater level of satisfaction with the leg ulcer service than those without a local specialist.

Community nurse questionnaire:

Three hundred and sixty (82%) nurses replied. Two hundred and forty six (68%) indicated that the diagnosis of the cause of ulceration was usually made by both the GP and the nurse but the choice of treatment was most often made by the nurse alone. The great majority (69%) did not have access to a local leg ulcer clinic and only 34 (9%) indicated that they had access to management protocols, almost 90% of nurses expressing a need for protocols. Both questionnaires revealed a lack of specialist support, dedicated leg ulcer clinics, better education and training, and leg ulcer management protocols.

Conclusion:

Serious deficiencies in the support available for community care of leg ulcer patients have been identified. The situation requires to be remedied if more cost-effective outcomes for leg ulcer patients are to be achieved.

Randomised Trial Comparing Two Four-Layer Bandage Systems in the Management of Chronic Leg Ulceration

Objective:

To compare a new four-layer bandage system (Profore) with the original 4LB in the closure of chronic leg ulceration.

Design:

Prospective randomised stratified parallel-groups open trial.

Methods:

Patients newly presenting to community leg ulcer services with chronic leg ulceration were screened for inclusion in this trial. Patients with arterial disease (ankle brachial pressure index <0.8) and causes of ulceration other than venous disease were excluded. In patients with bilateral ulceration, the limb with the larger area of ulceration was studied. The ulcer was dressed with a simple low-adherent dressing and all bandages were changed weekly unless required more frequently. Patients were randomised to receive either the original four-layer bandage or the newer system (Profore).

Results:

In all 233 patients were randomised, of whom 232 attended at least one follow-up visit (115 original, 117 Profore). At 12 weeks complete healing of the ulcerated limb, analysed by ‘intention-to-treat’ was 60% using the original 4LB compared with 72% using Profore. The difference of 11.8% (95% confidence interval (CI) −0.3% to 23.9%) had largely disappeared after 24 weeks, with 73% healed using the original 4LB and 76% using Profore, a difference of 3.0% (95% CI −8.2% to 14.2%). After 24 weeks of treatment the Kaplan-Meier estimate of complete healing was 82% using the original system and 84% using the Profore system. Overall, there was a higher healing rate for patients on Profore (hazard ratio = 1.18, 95% CI 0.87 to 1.59), but this did not achieve statistical significance ( p = 0.28).

Conclusion:

Ulcer healing using the newer Profore system is as good as with the original four-layer system.

Venous Disease: The New International Challenge

This paper reviews data on the socio-economic aspects of venous disease and venous insufficiency. It will cover data on the burden of disease and the effects of venous insufficiency on quality of life. It will also cover varicose veins, chronic venous insufficiency and venous ulcers of the leg. The use of the WHO International Classification of Diseases allows for comparisons across countries, with costs expressed not only in local currency, but also in terms of ECUs and as a percentage of health care costs.

The paper presents estimates on the costs of venous disease in the UK, France and Germany. Using standard diagnoses, costs are estimated to amount to 1.5–2.0% of total health care expenditure in these three countries. This is divided between inpatient, outpatient and community nursing programmes. Prescribing costs for venous diseases range from 0.26% of the total in the UK to 5.38% in France, with Germany in the middle of the range at 2.87%. The paper also summarizes costs in terms of reduced quality of life and loss of work-time. In Germany venous diseases contributed significantly to total disability, accounting for 1.2% of invalidity days in the late 1980s.

As a result of dissatisfaction with current treatment programmes there have been moves towards new ones. The paper sets out the evidence on innovations in care through investment programmes aimed at reducing costs and improving efficacy. Current developments in Britain, Germany and France are set out, summarizing likely costs and benefits.

Validation of the Lymphoedema Quality-of-Life Questionnaire (LYMQOL) in Dutch Patients Diagnosed with Lymphoedema of the Lower Limbs

BACKGROUND

The Lymphoedema Quality-of-Life Questionnaire is a validated disease-specific instrument to measure the impact of lymphoedema on patients' lives. In this study, we tested its psychometric properties and validated the use of the questionnaire in its Dutch translation.

METHODS

We obtained the answers to a standardised questionnaire, including Lymphoedema Quality-of-Life Questionnaire and Short-Form (36) Health Survey, twice at an interval of 2 weeks in 60 patients with lower limb lymphoedema. Feasibility was tested on the basis of missing responses and response distribution. Structure was studied using factor analysis. The reliability of the Lymphoedema Quality-of-Life Questionnaire was assessed using Crohnbach's α and test-retest reliability. Construct validity was tested by correlating Lymphoedema Quality-of-Life Questionnaire scores with the Short-Form (36) Health Survey scores.

RESULTS

The response rate was 88.2%. One of the 22 items missed >10% of responses; another showed a borderline ceiling effect. Internal consistency was good and test-retest reliability was excellent. The Lymphoedema Quality-of-Life Questionnaire correlated well with the physical component of the Short-Form (36) Health Survey and moderately with the mental component, suggesting that its construct validity was good.

CONCLUSION

The Dutch Lymphoedema Quality-of-Life Questionnaire can be used for health-related quality-of-life research in lower limb lymphoedema patients.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1% of people at some time in their lives and are often painful. The main treatments are compression bandages and dressings. Topical treatments to reduce pain during and between dressing changes are sometimes used.

OBJECTIVES

To determine the effects of topical agents or dressings for pain in venous leg ulcers.

SEARCH METHODS

For this third update the following databases were searched: Cochrane Wounds Group Specialised Register (searched 9 May 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4); Ovid MEDLINE (2009 to April Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations May 08, 2012); Ovid EMBASE (2009 to 2012 Week 18); and EBSCO CINAHL (2009 to May 2 2012). No date or language restrictions were applied.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of topical agents or dressing for the treatment of pain in venous ulcers were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed trial selection, data extraction and risk of bias assessment.

MAIN RESULTS

Six trials (343 participants) evaluated Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream for the pain associated with ulcer debridement. The between-group difference in pain measured on a 100 mm scale was statistically significant in favour of EMLA (MD -20.65, 95% CI -12.19 to -29.11). No significant between-group differences in burning or itching were observed.Two trials (470 participants with venous leg ulcers) evaluated ibuprofen slow-release foam dressings for persistent venous leg ulcer pain. Compared with local best practice, significantly more participants in the ibuprofen dressing group achieved the outcome of >50% of the total maximum pain relief score between day 1 and day 5 than participants in the local best practice group (RR 1.63, 95% CI 1.24 to 2.15). The number needed to treat was 6 (95% CI 4 to 12). In the second trial, compared with an identical non-ibuprofen foam dressing, there was no statistically significant difference in the proportion of participants experiencing slight to complete pain relief on the first evening of treatment.Limited data were available to assess healing rates or adverse events.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that ibuprofen dressings may offer pain relief to people with painful venous leg ulcers. EMLA (5%) appears to provide effective pain relief during the debridement of venous leg ulcers. Further research should consider standardised pain assessment methods and assess both the effect on ulcer healing and the impact of long term use of these treatments.

Cost-of-illness of leg ulcers in the community

Leg ulcer management is complex, time-consuming and of high socio-economic importance. Data on cost-of-illness in leg ulcer care are sparse. The objective of this study was to evaluate the cost-of-illness in leg ulcer treatment in the metropolitan area of Hamburg. About 147 institutions involved in wound care participated in a cross-sectional study. Patients consecutively recruited underwent a standardised interview and clinical examination. Main economic outcomes were direct, indirect and intangible costs from a societal perspective. Five hundred and two patients with a mean age of 71 years and mean wound duration of 9 years were enrolled. Annual total costs summed up to a mean of 9060€ /patient/year (8288€ direct, 772€ indirect costs). Direct costs carried by statutory health insurances amounted to 7680€ , patients themselves paid on average 607€. Leg ulcer is associated with high costs for health insurances, patients and the society. Exploratory predictor analyses suggest that early, interprofessional disease-management could lower treatment costs.

Venous leg ulcers and the impact of compression bandaging

Venous leg ulcers are a major health issue in terms of financial burden to the NHS, nurses' input, and physical, psychological and social impact to the patient. The best practice management of leg ulcers is the application of high compression, which is a complex task and requires substantial skill and knowledge. Healing and recurrence rates are poor in some cases and this adds to the physical and psychosocial impact, as well as the financial burden. Many of the sequelae of ulceration hinder patients' ability to tolerate treatment. Nurses must acknowledge the difficulties patients face and become skilled in holistic assessment, care planning and the delivery of patient-focused best practice.

Benefit evaluation in the therapy of chronic wounds from the patients' perspective--development and validation of a new method

Assessing therapeutic benefit of any drug and medical device is essential in registration and cost reimbursement decisions in Germany and in many nations. In this study, a method for the assessment of patient-relevant benefits in wound therapy was developed and validated. A total of 83 items on treatment benefit from the patients' perspective were collected in an open survey, including n = 50 patients with chronic wounds. The item pool was compiled to a list of 22 items by an interdisciplinary panel of experts including patients. The item list is presented prior to therapy to assess patient-relevant treatment needs and during or after therapy to establish if benefits have been attained. A weighed patient benefit index (PBI) is calculated from the items of both questionnaires. The instrument was examined for practical feasibility, reliability, and validity in a prospective study involving n = 172 patients with acute or chronic wounds treated by vacuum-assisted therapy. Validation criteria were: change in generic and disease-specific quality of life; judgment of efficacy by patients and physicians; treatment satisfaction; patients' willingness to recommend the therapy to others. Construct validity was given for all criteria applied. Cronbach's alpha was 0.88. The instrument was well-accepted by patients and rated relevant for the assessment of benefit in wound treatment.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1 per cent of people at some time in their lives. The main treatments are compression bandages and dressings. As these ulcers are often painful some clinicians choose particular dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes.

OBJECTIVES

To assess the effectiveness of dressings, local anaesthetics or topical analgesia for pain relief in venous leg ulceration.

SEARCH STRATEGY

For this update the search strings were revised and the following databases were searched: The Cochrane Wounds Group Specialised Register (Searched 16/12/09) The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 50; EBSCO CINAHL - 1982 to December 16 2009. No date or language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials which evaluated local interventions used to relieve venous leg ulcer pain were considered. Pain was defined as either persistent pain or pain at dressing changes or debridement. Ulcer healing and reported adverse events were also considered as further outcomes.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two review authors who independently assessed the potential trials.

MAIN RESULTS

Two trials evaluating interventions for persistent venous leg ulcer pain were identified for this review update. Both studies evaluated ibuprofen slow release foam dressings; one comparing it with local best practice and the other with an identical foam comparator. The primary end point for both studies was "pain relief achieved". When compared with a foam dressing alone, there was no evidence of a statistically significant effect of the ibuprofen foam dressing in terms of achieving some pain relief the first evening after treatment: 74% in the ibuprofen group (46/62) had pain relief compared with 58% (35/60) in the foam group (no significant difference: RR 1.27, 95%CI 0.98 to 1.65). In the second study 100% (32/32) of people with venous ulcers achieved some pain relief with the ibuprofen dressing on the first evening of treatment compared with 93% (26/28) in the local best practice group (no significant difference: RR 1.08, 95% CI 0.96 to 1.21). Pooling these studies in a meta-analysis (using a random effects model as significant heterogeneity present (p=0.1), I(2) = 64%) there is no evidence that ibuprofen dressings increase the pain relief experienced by the first evening of use (RR 1.15, 95% CI 0.91 to 1.44). We were not able to extract sufficient data to combine other pain outcomes from these trials. There was no difference in healing rates but slightly more adverse events with ibuprofen dressings than with a similar foam dressing without ibuprofen.Six trials evaluated interventions for the pain associated with debridement and were considered sufficiently similar to pool. There was a statistically significant reduction in debridement pain scores with 5% Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream; the difference in means (measured on a 100 mm scale) was 20.6 mm (95% CI 12.19 to 29.11). Of these six trials, only one small trial measured healing as an outcome and found no difference in the numbers of ulcers healed at the end of the study.

AUTHORS' CONCLUSIONS

There is no evidence that ibuprofen dressings offer pain relief, as measured at the first evening of use, to people with painful venous leg ulcers compared with foam dressings or best practice.EMLA appears to provide effective pain relief for venous leg ulcer debridement but the effect (if any) of EMLA on ulcer healing remains unknown.

Psychological factors in leg ulceration: a case-control study

BACKGROUND

There is increasing recognition of the role that psychological status plays in the development and outcomes of chronic disease, but little understanding of its importance in chronic leg ulceration.

OBJECTIVES

To examine psychological health and perceived social support in patients with chronic leg ulceration.

METHODS

Patients with leg ulceration within a defined population were matched for age and gender (1:1) with community controls in a matched case-control study. Analysis was by conditional logistic regression and matched t-test analysis.

RESULTS

Ninety-five patients (60 women and 35 men; 59% aged over 75 years) were identified and matched to the same number of controls. Cases had significantly poorer health-related quality of life in all domains of the Nottingham Health Profile (all P < or = 0.001), compared with controls. Levels of depression (Hospital Anxiety and Depression Scale) were significantly greater in the patient group (mean 5.3 vs. 3.6, P < 0.001). Social support (Medical Outcomes Study Social Support Survey scale) showed significantly fewer social networks and less perceived social support in patients than controls (P = 0.008). Patients used significantly fewer coping strategies (COPE scale) than controls, particularly with regard to problem-focused coping strategies.

CONCLUSIONS

Patients with leg ulceration experience poor psychological health with a greater risk of depression, less perceived social support and greater social isolation. Systems of care should offer an environment that reduces social isolation and increases support to this patient group.

Dressing-related pain in patients with chronic wounds: an international patient perspective

This cross-sectional international survey assessed patients' perceptions of their wound pain. A total of 2018 patients (57% female) from 15 different countries with a mean age of 68.6 years (SD = 15.4) participated. The wounds were categorised into ten different types with a mean wound duration of 19.6 months (SD = 51.8). For 2018 patients, 3361 dressings/compression systems were being used, with antimicrobials being reported most frequently (n= 605). Frequency of wound-related pain was reported as 32.2%, 'never' or 'rarely', 31.1%, 'quite often' and 36.6%, 'most' or 'all of the time', with venous and arterial ulcers associated with more frequent pain (P= 0.002). All patients reported that 'the wound itself' was the most painful location (n= 1840). When asked if they experienced dressing-related pain, 286 (14.7%) replied 'most of the time' and 334 (17.2%) reported pain 'all of the time'; venous, mixed and arterial ulcers were associated with more frequent pain at dressing change (P < 0.001). Eight hundred and twelve (40.2%) patients reported that it took <1 hour for the pain to subside after a dressing change, for 449 (22.2%) it took 1-2 hours, for 192 (9.5%) it took 3-5 hours and for 154 (7.6%) patients it took more than 5 hours. Pain intensity was measured using a visual analogue scale (VAS) (0-100) giving a mean score of 44.5 (SD = 30.5, n= 1981). Of the 1141 who reported that they generally took pain relief, 21% indicated that they did not feel it was effective. Patients were asked to rate six symptoms associated with living with a chronic wound; 'pain' was given the highest mean score of 3.1 (n= 1898). In terms of different types of daily activities, 'overdoing things' was associated with the highest mean score (mean = 2.6, n= 1916). During the stages of the dressing change procedure; 'touching/handling the wound' was given the highest mean score of 2.9, followed by cleansing and dressing removal (n= 1944). One thousand four hundred and eighty-five (80.15%) patients responded that they liked to be actively involved in their dressing changes, 1141 (58.15%) responded that they were concerned about the long-term side-effects of medication, 790 (40.3%) of patient indicated that the pain at dressing change was the worst part of living with a wound. This study adds substantially to our knowledge of how patients experience wound pain and gives us the opportunity to explore cultural differences in more detail.

The venous leg ulcer quality of life (VLU-QoL) questionnaire: development and psychometric validation

To develop and validate a disease-specific quality of life (QoL) measure, based on the conceptual model of the SKINDEX-29 for patients with a chronic venous leg ulcer (VLU), in-depth interviews, and focus groups of patients (n=36) with VLU were used to generate VLU-specific items. These items were added to selected SKINDEX-29 items that were adapted for use in VLU. Further samples of VLU patients were used for item reduction (n=124) and to assess the psychometric properties of the new tool (n=120). The final VLU-QoL contained 34 items: 17 items adapted from the SKINDEX-29 and 17 VLU-specific items. Factor analysis of the items confirmed the existence of three hypothesized domains: Activities (12 items), Psychological (12 items), and Symptom Distress (10 items). Reliability in terms of internal consistency and test-retest reliability was found to be good. The measure was also found to be valid and responsive to clinical change. The VLU-QoL has good psychometric properties. The instrument's sensitivity to differences in clinical outcome and responsiveness to change in clinical parameters makes it a useful tool to assess the outcomes of treatment from the patients' perspective.

Leg ulceration in Portugal: quality of life

This study was undertaken to examine the impact of chronic leg ulceration on patients' health-related quality of life in an audit of practice in Lisbon, Portugal, and to observe the changes following 12 weeks of treatment. A questionnaire was administered at entry into an observational study and following 12 weeks of treatment. Patients entering the study were asked to complete the Nottingham Health Profile (NHP), Euroqol and visual analogue (VA) pain questionnaires at entry and after 12 weeks. Principal analysis compared final scores with those found at baseline and compared results with Portuguese normative data. In total, 98 patients entered the study and completed the initial questionnaire, with 68 (69.3%) patients completing the follow-up questionnaire. There were significantly (P < 0.001) higher scores for the patients compared with normative data for all domains of the NHP (all P < 0.001). Improvements were noted for all NHP scores after 12 weeks, although only bodily pain showed a significant improvement [mean difference (d) = 10.5, P = 0.003], with significant improvement also in Euroqol (d = 0.10, P = 0.027). Energy and social isolation improved substantially in the eight (11.8%) patients whose ulcers healed, but did not achieve statistical significance, although VA pain score did (d = 4.85, P < 0.001). Patients suffering from leg ulceration show modest improvements in perceived health following 12 weeks of usual care in Portugal. Improvements in practice may enhance the magnitude of these improvements.

Pain in chronic leg ulcers

OBJECTIVES

Describe the characteristics of pain in patients with chronic leg ulcers, correlate these descriptions with the characteristics of the ulcers and with patients' sociodemographic data, and determine the measures used for pain management.

DESIGN

Descriptive and cross-sectional study with quantitative approach.

SETTING AND SUBJECTS

The convenience sample was composed of 90 patients with chronic leg ulcers drawn from 4 outpatient departments in Sao Paulo and Curitiba.

INSTRUMENTS

Intensity and quality of patients' pain were determined using a 0-10 numeric pain intensity rating scale and a short version of the McGill Pain Questionnaire.

METHODS

After gaining ethics committee approval, patients were selected during their ambulatory visits and interviewed by researchers. Data obtained were analyzed using the Kolmogorov-Smirnov Normality test, Mann-Whitney test, Chi-Square test, and Spearman's Correlation coefficient.

RESULTS

Seventy-three (81.11%) patients had venous ulcers. The mean pain intensity reported was 3.10 (SD = 3.15), the mean intensity of the "worst pain of the week" was 7.56 (SD = 2.96), and the mean intensity of the "best pain of the week" was 2.05 (SD = 2.37). The McGill Questionnaire showed that sensitive descriptors were most frequently used to describe the pain. Statistically significant correlations (P < .05) were observed. The most intense pain was reported in subjects from the lowest income bracket studied and female gender and was correlated with alterations in sleep, movement, walking, and mood. Nonsteroidal antiinflammatory drugs were most commonly used (70%) for pain management.

CONCLUSIONS

This study indicates the need for more attention and understanding on the part of healthcare workers regarding leg ulcer pain and its characteristics and the need for specific and effective procedures designed to contribute to the improvement in quality of life of these individuals.

Venous leg ulcer treatment and practice--part 1: the causes and diagnosis of venous leg ulcers

This article, the first of a series of four on venous leg ulceration, discusses theories relating to the pathophysiology underlying the condition, and the range of diagnostic procedures undertaken to establish that ulceration is of venous origin.

Randomized trial of two foam dressings in the management of chronic venous ulceration

A multicenter prospective randomized clinical trial was undertaken to compare two foam dressings (Allevyn Hydrocellular, Smith & Nephew and Mepilex, Molnlycke Health Care AB) in the management of chronic venous leg ulceration. Patients were also randomized to two compression bandage systems (4-layer vs. cohesive short stretch) as a factorial design. Those with causes of ulceration other than venous disease were excluded. In all, 156 patients met the entry criteria and were randomized from the 12 clinical centers with a median (range) ulcer size of 4.33 (0.33-123.10) cm(2). After 24 weeks a total of 100 (64.1%) patients had complete ulcer closure, 46 (29.5%) had withdrawn from the trial, nine (5.8%) remained unhealed and one patient died. Of the patients randomized to Mepilex, 50/75 (66.7%) had complete ulcer healing compared with 50/81 (61.7%) on Allevyn. The hazard ratio for healing after adjustment for bandage type and trial center was 1.48 (95% C.I. 0.87-2.54, p=0.15), which only marginally changed following adjustment for baseline variables, neither of which achieved statistical significance (p=0.16). Withdrawal rates were similar between groups (23, 30.7% Mepilex vs. 23, 28.4% Allevyn). Pain improved following treatment with both dressings (p<0.001), but with no difference between dressings.

'Look after your legs': patients' experience of an assessment clinic

Venous leg ulcers are a chronic, recurring condition and a major cause of morbidity, especially in older people. Two inner city district nursing teams initiated a weekly, nurse-led, leg ulcer assessment clinic, and a monthly support group for patients with healed or almost healed leg ulcers. The group supports and empowers patients with self-care 'look after your legs' health promotion messages. The support group uses a similar model to the expert patient programme (Department for Health, 2001). Patients in the group coined the unique name 'patient ambassador'. Patient ambassadors, with nursing support, are used to promote self care and lifestyle changes to members of the group to prevent recurrence of leg ulceration. The aim of the research reported here was to evaluate teh 'Look after Your Legs'(LAYL) service and the benefit to others of the patient ambassador role.

Longer-term changes in quality of life in chronic leg ulceration

Studies that have examined patients' health-related quality of life have consistently shown improvements following intensive and effective treatments over relatively short follow-ups. However, little is known of the longer-term effects of treatment on patients. As part of a study in southwest London, United Kingdom, all patients having a current leg ulcer were examined (n = 113) and those who were able completed the Nottingham Health Profile (n = 95) and were then followed up at 24 and 48 weeks. The patients had a mean age of 76 +/- 13 (SD) years, with 60 (63.2%) being women. Before the study, the ulcer had been present for a median of 8 months (range 0.5-144), and a median area of ulceration of 4.0 cm2 (range 0.5-171.5 cm2). After 24 weeks, there was a significant improvement in pain (mean difference [d] = 9.6, p = 0.002), which was true for both the 41 patients with ulcers present (d=10.07, p = 0.013) and the 43 patients whose ulcers had healed (d = 11.46, p = 0.047). However, after 48 weeks, these improvements had been reduced in both groups (healed ulceration d = 5.76, unhealed patients d = 6.41). Energy, which had improved after 24 weeks in the patients whose ulcers, had healed (d = 11.46), deteriorated in both patient groups after 48 weeks (healed = -5.67, unhealed = -13.43). Mobility status was maintained with healed ulceration (d = 1.05) but deteriorated with unhealed ulceration (d = -13.19). The positive effects of treatment on health-related quality of life may not be sustained over time. This may be a consequence of the general deterioration in the health status of these elderly patients as they age.

Assessment of health-related quality of life in patients with lymphedema of the lower limb

The purpose of this study was to examine the use of a number of tools in the evaluation of health-related quality of life in patients with lower limb lymphedema, and to determine the consequences of cancer history and concurrent leg ulceration. Patients in one health trust having lower limb lymphedema were identified and interviewed at entry and after 24 weeks. The short form-36 (SF-36), modified Barthel scale, McGill short form pain questionnaire, and Euroqol were administered at both time points. Of the 164 (median age=76.9 years, 70.7% women) patients who comprised the study population, 15.2% had a history of cancer and 30.4% had coexisting current leg ulceration. Internal consistencies were high for all scales (Cronbach's alpha >0.80). There were high ceiling effects for a number of SF-36 scores, and high floor effects in these and the McGill short form pain questionnaire, scales. Despite these limitations, there was strong evidence that treatment led to significant improvements in six of eight scores of the SF-36, three of three scores of the McGill short form pain questionnaire and the modified Barthel scale (all p<0.05). The improvement in physical functioning was significantly greater for patients who entered the study with a leg ulcer (mean different=9.1, 95% confidence interval 2.1-16.1, p=0.011). Patients treated with compression bandaging had significantly greater improvements for physical functioning (10.2) than those treated with compression hosiery (-1.5) or no treatment (-2.0), p=0.001. Of the tools assessed, the SF-36, appears to be the most appropriate for use in this patient group.

Patients’ perceptions of the impact of treatments and products on their experience of leg ulcer pain

OBJECTIVE

Very little research has explored patients' experience of pain with different cleansing agents and dressings. We therefore undertook a longitudinal study of their impact on leg ulcer pain.

METHOD

Patients with leg ulcers referred to community nurses were eligible to participate. They were followed up for six months, completing questionnaires about the impact on pain of each wound treatment used. A treatment episode was defined as the use of a wound cleansing agent, primary dressing and bandages. When one aspect of treatment changed, a new treatment episode began.

RESULTS

There were 210 treatment episodes for 96 leg ulcer patients. In 206 episodes cleansing agents were used. Cleansing caused pain in 22% of episodes and relieved pain in 27%. Of the five most commonly used dressing types, low-adherent dressings were the least likely to cause pain. Only 56% of patients were able to tolerate full compression bandaging and pain was the most common reason for non-compliance.

CONCLUSION

A substantial proportion of patients felt that leg ulcer treatments caused pain. A greater emphasis on the impact of treatment on pain and healing is warranted both clinically and in research.

Pressure Ulcer Pain

OBJECTIVE

To describe and interpret the complexities of the pain experienced by persons with painful pressure ulcers.

DESIGN

Heideggerian hermeneutic phenomenology.

SETTING AND SUBJECTS

Ten participants with pressure ulcers hospitalized in an acute-care community hospital were interviewed.

METHODS

Multiple taped interviews, transcripts, and field notes were collected over an 8-month period. Data analysis occurred over a 16-month period and included an initial process of naming the text, identifying themes, and writing the interpretations of each participant's story. Secondary analysis comprised reading across the texts for commonalities and shared meanings. These data were related to other literature sources, shared with a team of researchers familiar with the Heideggerian hermeneutic phenomenology process, and with wound, ostomy, and continence nurses.

RESULTS

A total of 22 themes and 1 constitutive pattern were identified. Participants with varying stages of pressure ulcers shared poignant stories about their pain. Many related their accounts and instances of actions by health personnel and the treatment interventions that were painful. Some related their accounts of communication failures that contributed to stress, tension, and anxiety.

CONCLUSIONS

The findings of this study clearly indicate the need for increased attention to pain assessment and pain management in nursing education, nursing practice, and nursing research. The findings also suggest that the commonly used definition of pain is insufficient and needs revision.

Refractory Venous Leg Ulcers: A Study of Risk Factors

BACKGROUND

Although certain risk factors for poor healing of leg ulcers have been identified, data concerning the characteristics of refractory ulcers have not been specifically studied in the literature.

OBJECTIVE

To study the characteristics of refractory venous leg ulcers.

METHODS

We retrospectively studied prognostic factors for healing in patients with refractory venous leg ulcers followed and treated in our dermatology department between January 1993 and January 2000. Each patient included in this study was compared with two patients matched for age and gender and presenting leg ulcers with normal healing, followed during the same period.

RESULTS

Thirty-two of 571 patients with leg ulcers were included. The study population consisted of 20 females and 12 males with a mean age 73.5 years. The control population comprised 64 patients, 40 females and 24 males, with a mean age of 73 years. Univariate analysis demonstrated the negative prognostic impact of several previously identified factors (including surface area and history of the ulcer). In particular, multivariate analysis identified four main risk factors for refractory ulcer that are often associated in these patients: associated arterial disease, presence of post-thrombotic popliteal sequelae, recurrence of the ulcer, and disability.

CONCLUSION

Four main risk factors that are often associated were identified, indicating the multifactorial nature of these refractory ulcers.

Health-related quality of life during four-layer compression bandaging for venous ulcer disease: a randomised controlled trial

BACKGROUND

Venous leg ulceration is a chronic debilitating condition which negatively impacts on patients' quality of life. Despite the application of gold standard treatment a number of patients suffer from 'slow to heal' ulcers, which can require treatment for years.

AIMS

The aim of this study was to compare the effects of four-layer compression bandaging (4LB) for treating venous leg ulcers with other available treatments on health-related quality of life duringtreatment.

METHODS

In this pragmatic trial, 200 patients with venous leg ulceration were randomised either to 4LB (intervention group; n = 100) or to continue their usual system of care (control group; n = 100). Analysis was by intention to treat; quality of life measurements were taken at randomisation and after six weeks of treatment.

RESULTS

4LB provided greater quality of life benefits than the control group particularly in the area of physical activity and social functioning.

CONCLUSION

Due to the long-term nature of treatment for many of these patients, the effects on quality of life should be considered when prescribing treatment. This study has shown that 4LB significantly improves the quality of life of patients during treatment for venous leg ulceration.

Venous Ulcer Services in the United Kingdom

OBJECTIVES

To obtain comprehensive information about venous ulcer services throughout the United Kingdom (UK).

DESIGN

Questionnaire based survey.

MATERIALS

Questionnaire.

METHODS

Letters about venous ulcer services were sent to consultant vascular surgeons in all areas of the UK (total 181). Questionnaires were then directed to the appropriate clinician in each area.

RESULTS

Responses were received from 177 (98%) areas. Fifteen (8%) had no dedicated service. Completed questionnaires were returned for 112 (63%) areas. Fifty-six (54%) services were managed by acute hospitals, 29 (28%) by primary care (community) and 19 (18%) jointly. Doctors supervised services in 65 (64%) (vascular surgeons 49, dermatologists 12, both 4) and nurses in 31 (33%). New referrals per week were 1-50 based on audit (33%) or estimates (67%). Sixty-three (58%) services had no database. Written guidelines existed for 76% services (90% nurse-supervised and 64% doctor-supervised services--p<0.02).

CONCLUSIONS

Dedicated venous ulcer services have been shown to improve healing rates and quality of life. Although now present in most areas of the UK, their organisation varies considerably and many are not based in the community, near patients homes. This survey provides a benchmark for comparison with venous ulcer services in other countries.

Improved healing rates for chronic venous leg ulcers: pilot study results from a randomized controlled trial of a community nursing intervention

Venous leg ulcers are a frequent source of chronic ill-health and a considerable cost to health-care systems. This paper reports pilot study results from a randomized controlled trial to determine the effectiveness of a community-based 'Leg Club' environment on improving healing rates of venous leg ulcers. Leg Clubs offer a setting where people with similar problems can socialize in a supportive, information-sharing environment. A sample of 33 clients with a below-knee venous leg ulcer were randomized to treatment, either in their own homes or in a community Leg Club. Treatment was provided to all participants, whether in the control group or intervention group, by a team of trained wound-care nurses following evidence-based assessment and treatment guidelines. Data were collected on admission to the study and at 12 weeks from admission. Results showed a significant improvement in healing in the intervention group compared to the control group, as measured by ulcer area size and Pressure Ulcer Scale for Healing scores. These results suggest that a community Leg Club environment provides benefits additional to wound care expertise and evidence-based care. Knowledge gained from this study provides evidence to guide service delivery and improve client outcomes.

Four-layer bandaging: from concept to practice

The 4-layer bandage was originally designed to provide sustained leg compression to patients with venous leg ulcers. Since then, the practice of 4-layer bandaging has become widespread in the United Kingdom. Ulcer healing rates vary for a number of reasons. This review, by a member of the original design team, seeks to discuss reasons of varying success and offers advice for its appropriate usage.

Cost effectiveness of using carboxymethylcellulose dressing compared with gauze in the management of exuding venous leg ulcers in Germany and the USA

OBJECTIVE

To assess the cost effectiveness of using carboxymethylcellulose dressing (CMCD; Aquacel Hydrofiber) compared to gauze in the management of exuding venous leg ulcers in Germany and the USA.

DESIGN AND SETTING

This was a modelling study performed from the perspective of payers (i.e. the sickness funds in Germany and the community sector in the USA).

METHODS

Clinical outcomes attributable to managing exuding venous leg ulcers were obtained from the published literature in the English language. These data were combined with resource utilisation estimates derived from a panel of clinicians enabling us to construct two decision models depicting the management of venous leg ulcers with CMCD or gauze over 18 weeks in Germany and the USA. The models were used to estimate the cost effectiveness of CMCD compared to gauze in the management of exuding venous leg ulcers in both countries.

MAIN OUTCOME MEASURES AND RESULTS

Starting treatment with CMCD instead of gauze in both Germany and the USA is expected to heal 30% of ulcers within 18 weeks compared to 13% with gauze (p = 0.003). The healthcare cost of starting treatment with CMCD or gauze in Germany is expected to be Euro2020 and Euro 2654 respectively at 18 weeks. Additionally, the healthcare cost of starting treatment with CMCD or gauze in the USA is expected to be $3797 and $5288 respectively at 18 weeks. Hence, using CMCD instead of gauze is expected to increase the probability of healing within 18 weeks by 130% and reduce healthcare costs by at least 24%. The healthcare cost of managing CMCD-treated patients was less than that of gauze-treated patients in both countries due to decreased nursing and physician costs associated with a lower frequency of CMCD dressing changes compared to gauze dressing changes. If it were assumed that treatment with gauze in both countries heals 30% of ulcers within 18 weeks (i.e. is identical to CMCD), then the expected healthcare cost of using gauze would be reduced by only 3% (from Euro2654 to Euro2562 in Germany and from $5288 to $5148 in the USA).

CONCLUSION

Within the limitations of our model, starting management of an exuding venous leg ulcer with CMCD instead of gauze is the cost effective strategy in both Germany and the USA. Moreover, the purchase price of a leg ulcer dressing should not be used as an indication of the cost effectiveness of a given method of care.

The use of qualitative research methodologies to explore leg ulceration

Qualitative research is used increasingly within tissue viability and this article specifically presents its use within the body of literature on leg ulceration. This article offers a discussion of the key features of qualitative methodology, such as subjectivity, bracketing, rigour and the analytic process. Furthermore it will be shown that understanding the underpinning philosophical approach is essential for clinicians undertaking qualitative research. The rich data obtained through this approach will be presented, revealing how a person living with leg ulceration can be heard.

Diagnosis, assessment and management of mixed aetiology ulcers using reduced compression

Accurate diagnosis of mixed aetiology leg ulcers depends on detailed assessment by a trained practitioner. This paper, the fourth in a six-part series on leg ulcers, describes how reduced compression bandaging can achieve successful outcomes.

Does leg ulcer treatment improve patients' quality of life?

OBJECTIVE

To investigate the impact of 'disease' and treatment on quality of life in patients with venous leg ulceration.

METHOD

Sixty-five patients with venous leg ulcers were recruited and treated. At study entry and exit or following complete wound closure, whichever occurred first, each patient was assessed using the SF-36 quality-of-life questionnaire. Data analysis included an investigation of the study population as whole, differences between patients whose ulcers did and did not heal and between gender and age. Health domain means for all patients were compared with age equivalent norms (AENs) at both entry and exit.

RESULTS

There was a significant improvement in the SF-36 domains of bodily pain, health transition, mental health and social functioning for all 65 patients. Patients whose ulcers healed also showed a statistically significant improvement in the vitality domain. Patients whose ulcers did not heal had statistically significant improved scores for bodily pain and health transition. At entry all SF-36 values, except for general health, were lower than the AENs. On exit, scores for bodily pain, general health and mental health were comparable with the AEN; values for the remaining five domains increased at exit.

CONCLUSION

The results highlight that good wound management and effective compression therapy can improve quality of life in patients with venous leg ulceration, whether or not the patient's leg ulcer healed following treatment.

Disrupted lives: investigating coping strategies for non-healing leg ulcers

The aim of this study was to explore the lived experience of people who have non-healing venous ulcers using hermeneutic phenomenology. Unstructured interviews were carried out with five people who also completed a diary. Interpretative phenomenological analysis was utilized to identify themes and patterns. The core themes identified through analysis were biographical disruption, ways of coping, social implications and therapeutic relationships. The emergent themes reveal the impact of chronicity in participants' experience of chronic leg ulcers, their various emotional and problem-focused coping strategies and the positive role the district nurse plays in their lives. This study places leg ulceration within the body of literature on chronicity, linking nursing theory with the insights offered from health psychology.

Prevalence of leg ulceration in a London population

BACKGROUND

Current prevalence estimates of chronic leg ulceration are frequently based on studies from the 1980s. During the last decade, major changes have occurred in the application of evidence-based practice to this condition.

AIM

To determine the prevalence and cause of leg ulceration in a defined geographical population after 8 years of providing standardized evidence based protocols of care.

DESIGN

Prospective survey.

METHODS

Patients with leg ulceration of >4 weeks duration) within an integrated acute and community leg ulcer service were ascertained, interviewed and clinically assessed, using a standardized questionnaire on medical history, ulcer details and non-invasive vascular investigation to describe causes. Ulcers were classified by aetiology.

RESULTS

We identified 113 patients in a population of 252 000, giving a crude prevalence of 0.45/1000 (95%CI 0.37-0.54/1000): 0.34/1000 in men, 0.54/1000 in women. Rates were highly dependent on age, increasing to 8.29 (men) and 8.06/1000 (women) in those aged >85 years. Of the responders, 62/113 (55%) had their ulcer for >1 year. Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs; a further 21 had ulceration primarily due to arterial disease. Complex causes were present in 48 (35%) limbs, mostly venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%).

DISCUSSION

Our prevalence of chronic leg ulceration is approximately one-third of that predicted by previous studies using similar methodologies in the 1980s. Patients with ulceration have more complex aetiologies than previously recognized, which may be a consequence of both increasing ulcer chronicity and age.

Understanding the underlying causes of chronic leg ulceration

Leg ulcers are debilitating and have a significant negative impact on patients' quality of life. It is particularly important to understand the underlying causes of leg ulcers that are described as 'slow to heal' to ensure they are managed effectively.

Leg ulcers: a review of their impact on daily life

BACKGROUND

Current nursing care for leg ulcer patients often focuses on wound care and providing compression therapy. Nurses perceive leg ulcer patients as 'under-served' with regard to problems patients experience in daily life. An overview of patient problems is a first and essential step in the development of comprehensive nursing care.

AIMS AND OBJECTIVES

To gather information about the impact of leg ulcers on patient's daily life as described in quantitative and qualitative studies.

DESIGN

Systematic literature review.

METHODS

Medline and Cinahl databases were searched for venous leg ulcer studies, up to 2002; this was followed by the 'snowball method'. Studies were selected in accordance with preset criteria.

RESULTS

A total of 37 studies was included. All studies report that leg ulcers pose a threat to physical functioning. Furthermore, a negative impact on psychological functioning is reported and, to a lesser degree, on social functioning. Major limitations are pain and immobility, followed by sleep disturbance, lack of energy, limitations in work and leisure activities, worries and frustrations and a lack of self-esteem. Patients have a significantly poorer quality of life compared with healthy people. Finally, patients report problems with regard to follow-up treatment.

CONCLUSIONS

Having a leg ulcer has a major impact on a patient's life. There are indications of under-treatment of pain.

RELEVANCE TO CLINICAL PRACTICE

Keeping in mind that leg ulceration is notorious for its chronic character, the negative impact on patient's life implies that many patients suffer over longer periods of time. This emphasizes the need to focus on quality of life aspects in patient care. There is much to gain, especially concerning pain and mobility. The development of comprehensive care programmes is essential.

The clinical feasibility of natural medicine, venotonic therapy and horsechestnut seed extract in the treatment of venous leg ulceration: a descriptive survey

BACKGROUND

The primary treatment of choice for venous leg ulceration (VLU) is compression therapy; however, serious clinical issues demand the development of new treatments. An extract believed to promote VLU healing is Horsechestnut Seed Extract (HCSE).

METHODS

The clinical feasibility of HCSE in VLU was explored in a two-stage design. The second stage presented here, was a descriptive survey exploring current opinion and utilisation of natural therapies, venotonics and HCSE in VLU. A questionnaire mailed to 122 district nurses, 73 medical practitioners (MPs) and 53 clients with VLU resulted in a response rate of 32, 31.5 and 81 per cent, respectively.

RESULTS

Natural therapy and HCSE use for VLU was minimal in all groups. Half of all groups supported venotonics, with a similar proportion of nurses and clients utilising venotonics in practice. MPs were however less likely to utilise venotonics for VLU.

CONCLUSION

Whilst clinicians indicate that clinical evidence may influence the utilisation of HCSE in clinical practice, the evidence currently does not exist. Positive findings from well-designed trials may ameliorate the integration of natural medicine into mainstream practice.

Cardiff Wound Impact Schedule: the development of a condition-specific questionnaire to assess health-related quality of life in patients with chronic wounds of the lower limb

The purpose of this study was to develop and validate a questionnaire to measure the impact of chronic wounds (leg ulcers and diabetic foot ulcers) on patient health-related quality of life (HRQoL) and identify areas of patient concern. The Cardiff Wound Impact Schedule (CWIS) was created following a three-stage process. Stage 1 included a focus group (n=10) and a series of semi-structured interviews (n=13) to generate items for the questionnaire. Stage 2 involved piloting the 28-item questionnaire on 124 patients (64.5% with leg ulceration and 35.5% with diabetic foot ulceration): data from this stage were analysed using factor analysis. The reliability, validity and reproducibility of the resulting scale were assessed in Stage 3, a 3-month follow-up study of 135 patients in which patients completed the CWIS and the SF-36. Factor analysis identified three domains of HRQoL: physical symptoms and daily living, social life and well-being. There were no significant differences in scores across the wound types. Internal consistency was good (alpha=0.77-0.96) as was reproducibility (P<0.001). The CWIS was able to discriminate between those with healed ulcers and active ulcers (P<0.01). Construct validity was demonstrated by strong correlations between related items on CWIS and SF-36 (P<0.01-P<0.0001). The data suggest that CWIS has high internal consistency and the ability to discriminate between health states and good reproducibility. CWIS is a valid tool for studying the impact of chronic wounds of the lower leg on HRQoL. CWIS allows clinicians to identify items of patient concern, which can then be used to negotiate options of care most suited to individual patients.

Making sense of the venous leg ulcer debate: a literature review

Venous leg ulcers cause patients much distress. Treating them is expensive, with many hidden costs. As understanding of the causes and development of this condition improves, debate over the best treatments or treatment combinations is growing.

Pain in pure and mixed aetiology venous leg ulcers: a three-phase point prevalence study

OBJECTIVE

This study aimed to determine the point prevalence of venous leg ulcer pain over three seasons (autumn, winter and spring). It also collated profiles of individuals with venous ulceration and described the characteristics of people with and without venous leg ulcer pain.

METHOD

The study sample comprised 255 people with pure and mixed venous leg ulcers who were receiving care in a Canadian community leg ulcer service. Prevalence was determined by the number of individuals who had experienced pain in the past 24 hours. The profile of individuals was developed by analysing sociodemographic, circumstance-of-living, clinical and health-related quality-of-life data collected on admission to the leg ulcer service.

RESULTS

Over the three prevalence periods, the prevalence of pain for the total sample ranged from 48% to 54%. Prevalences at each of the study periods for individuals who had been receiving care for less than 13 weeks, and for the first measure of pain only, were almost identical, ranging from 48-59%. The mean pain-severity score was less than three (out of 10) in all three periods. Of the individuals with pain, 50% or more used analgesia and, of these, over 75% reported it was effective. The profile of participants with pain was similar to those without it, except that the former were significantly more likely to have osteoarthritis, a foot ulcer, to have been attending the leg service for a shorter time period and to have a lower SF-12 mental health component score.

CONCLUSION

These results demonstrate that leg ulcer management must include pain assessment and consideration of the factors that may be associated with pain. A large prospective repeated measures study is needed to increase understanding of the extent of pain, the use and efficacy of analgesia, and the factors that may be related to experiencing pain.

The measurement of leg ulcer pain: identification and appraisal of pain assessment tools

OBJECTIVE

To identify and compare the psychometric, clinical sensibility, and pain-specific properties of leg ulcer pain assessment tools for use as a guide for clinicians and researchers.

DESIGN

Pain assessment tools were selected for appraisal based on 4 inclusion criteria: (1) designed specifically to measure either quality and/or intensity of pain, (2) used in at least 2 different diseases and/or pain-inducing interventions in adults, (3) generic, and (4) patient self-reporting. The tools were appraised against psychometric properties, clinical sensibility attributes, and pain-specific issues. Two reviewers independently reviewed each abstract, with a third reviewer resolving any disagreements. Then the first 2 reviewers independently assessed the selected tools using the predetermined appraisal criteria.

RESULTS

Of 54 identified pain assessment tools, 5 (the pain ruler, the numerical rating scale, the visual analogue scale, the verbal descriptor scale, and the short-form McGill Pain Questionnaire) met the inclusion criteria. Each tool met the appraisal criteria to varying degrees.

CONCLUSIONS

The use of a pain assessment tool to measure leg ulcer pain is recommended. Clinicians must decide independently which factors are most important when selecting a tool. Although a specific pain assessment approach cannot yet be recommended, a 2-step pain assessment process is most practical. To optimize pain management, further study is needed to ensure that leg ulcer pain is accurately and reliably assessed.

Management of chronic leg ulcers by nurses working in the community in Sweden and the UK

OBJECTIVE

This study compared the management of chronic leg ulcers by nurses in community, primary health care and nursing home settings in Kronoberg, Sweden, and East Riding, UK.

METHOD

A questionnaire was sent to all nurses in the two areas enquiring about their occupational background, leg ulcer management, resource utilisation and education and training. It also asked about their preferred treatment choices for four types of chronic leg ulcers described in case studies. Response rates of 50% (UK) and 54% (Sweden) were achieved.

RESULTS

Nurses in the UK undertook diagnostic investigations of non-healing leg ulcers as part of the initial assessment, whereas in Sweden these were undertaken by physicians. In Sweden daily dressing changes were more frequent and often involved nurse auxiliaries. Patients and relatives almost never participated in dressing changes in the two countries. Sodium chloride was the most commonly used cleansing agent in the UK, as opposed to warm water in Sweden. The use of antibacterial/antiseptic dressings and antibiotics was more frequent in the UK. Nurses there also used scientific and professional literature more frequently. Swedish nurses experienced more problems in obtaining new information.

CONCLUSION

Differences exist between the two countries in leg ulcer management. These may be related to differences in the health-care systems, staff training and attitudes to evidence-based practice.