Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing

Abstract

Aims and Objectives

The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. The purpose of this study was to examine the biopsychosocial model of pain by assessing the relationships between pain, stress, inflammation and healing in people with chronic wounds.

Design

This was a 4‐week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds in a chronic care hospital in Canada.

Methods

Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. Participants were evaluated for pain by responding to the Brief Pain Inventory‐Short Form, the McGill Pain Questionnaire‐Short Form and the Leeds Assessment of Neuropathic Symptoms and Signs scale. Stress was measured by the Perceived Stress Scale (PSS). All wounds were assessed with the Pressure Ulcer Scale for Healing tool. The levels of matrix metalloproteinases were analysis by obtaining wound fluid from all participants.

Results

A total of 32 individuals with chronic wounds participated in the study. Correlation analysis indicated pain severity was positively and significantly related to pain interference, McGill Pain Questionnaire scores, neuropathic pain and matrix metalloproteinase levels. Logistic regression was used to determine the predictors for high or low perceived stress. The only significant variable that contributed to the stress levels was BPI‐I. Results suggested that participants who experienced higher levels of pain interference also had an increased odds to report high level of stress by 1.6 times controlling for all other factor in the model.

Conclusion

Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing.

1. BACKGROUND

A wound occurs when there is a breakdown of the skin resulting from tissue trauma and injury. ¹ However, hard‐to‐heal wounds do not always exhibit an orderly healing trajectory and they may last for months or years affecting ca. 1.67 per 1000 population globally at any given time. ² The number of chronic wounds continues to rise due to a rapidly ageing population and growing prevalence of obesity, diabetes and vascular diseases. ² The exorbitant societal and economic toll that is placed on the health system and individuals for ongoing care and management is well‐documented and indisputable. ³ Although the primary objective is often focused on healing of the wound, patients with various types of chronic wounds consistently relate pain to be of a higher management priority. In an international survey of people living with chronic wounds, over 60% of the respondents reported the experience of pain ‘quite often’ and ‘all the time’. ⁴ Pain is associated not only with poor quality of life but also adverse clinical outcomes. Woo and Sibbald ⁵ followed 111 subjects with wounds and compared pain levels among those who achieved complete wound closure at week 4 to those who did not. The mean pain intensity score was significantly higher among non‐healers.

The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. Stress triggers a cascade of physiological responses characterized by increased production of hormones (e.g., cortisol) that can lead to alteration in the immune system and delay in wound healing. ⁶ Research studies demonstrate that prolonged periods of stress can increase healing time. Ebrecht et al. ⁷ evaluated healing of acute wounds created by dermal biopsy among 24 healthy volunteers. Stress levels reported by the participants (Perceived Stress Scale [PSS]) were negatively correlated to wound healing rates 7 days after the biopsy (p < 0.05). Subjects exhibiting slow healing (below median healing rate) rated higher levels of stress during the study (p < 0.05) and presented higher cortisol levels 1 day after biopsy than the fast‐healing group (p < 0.01). According to results reported by Glaser et al. ⁸ high stress scores on the PSS were correlated to low levels of interleukin (IL)‐1 (p < 0.03) and IL‐8 in blister fluids (p < 0.04). Among post‐surgical patients, Broadbent et al. ⁹ also found that anxiety prior to the operation was a significant predictor for the diminished levels of matrix metalloproteinase 9 (MMP‐9) in the wound (β = 0.38, p = 0.03), as well as increased pain over the first 20‐h postoperative period (β = 0.51, p = 0.002). MMPs are commonly referred to as inflammatory proteases. MMPs comprise 20 enzymes; each requires a metal (such as zinc) to catalyse their activity. Studies have shown the proteases predominantly found in chronic wound fluid are MMP‐2, MMP‐8, MMP‐9 and the serine protease, elastase. ¹⁰ However, the investigators followed the subjects only for 20 h after the surgery; the long‐term effect of stress on the inflammatory response and wound healing remains unanswered. In a meta‐analysis of 17 studies, Walburn et al. ¹¹ validated the significant relationship between stress and wound healing; r = −0.42 (95% CI = −0.51 to −0.32) (p < 0.01). However, scientific inquiry of the relationship between pain, stress and healing of chronic wounds is lacking. A better understanding of this relationship will help develop treatment strategies for chronic wounds. The purpose of this study was to examine the relationship between pain, stress, inflammatory response (inflammatory proteases) and wound healing.

2. METHODS

2.1. Setting

This was a 4‐week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds who were admitted to a chronic care hospital in Canada. Approvals were obtained from the research ethics board of the participating institutions (West Park Health Centre, Ethics number: 18‐008‐WP; Queen's University Research Ethics Board, number 6006988). Subjects were provided with detailed explanation of the study, and they were informed of the right to withdraw from the study at any time. Informed written consent was obtained for all participants. Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. All patients were able to understand, speak, read and write English. Individuals who are considered to be incompetent, palliative and psychotic were excluded. Based on the inclusion and exclusion criteria, nurses from the hospital initially approached potential participants. The research team contacted those who expressed interest in the study and described the goals and methods of the study. After informed consent was obtained, participants were asked to respond to several questionnaires about their pain and stress at the beginning of the study and at reassessment after 4 weeks:

1. The Brief Pain Inventory‐Short Form ¹² : Participants rated their pain on a numerical rating scale of 0–10 at the time of responding to the questionnaire before dressing changes to indicate current, worst, least and average pain levels over the previous week. A composite of the four pain items was calculated for overall pain severity. Participants also indicated the degree to which pain interferes with mood, walking and physical activity, work, social activity, relations with others and sleep using numeric 0 to 10 scales. The mean of these scores was used as a pain interference score.

2. McGill Pain Questionnaire‐Short Form (MPQ‐SF) ¹³ : The MPQ‐SF contained two dimensions, 11‐word descriptors referring to the sensory quality of pain and four related to the affective dimension of pain. Each word was rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate or 3 = severe.

3. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale ¹⁴ : The LANSS was used to evaluate pain of neuropathic origin. There were seven items including five sensory descriptors and two items for bedside examination of sensory dysfunction. For the purpose of this study, only the sensory descriptor scale was used. The maximum score of the tool was 16. The ability of the LANSS to differentiate neuropathic from nociceptive pain was considered adequate with sensitivity of 85% and specificity of 80%.

4. The PSS ¹⁵ : The PSS allowed the participants to indicate on a 5‐point Likert scale from ‘never’ to ‘very often’ the degree to which the individual experiences stress in various life situations. There were 10 questions on the scale adding up to a maximum score of 40.

Wounds were assessed with the Pressure Ulcer Scale for Healing (PUSH) tool ¹⁶ that consisted of three parameters: the size by measuring the longest length and the longest width, amount of exudate and wound surface appearance. All assessments were done by the investigator to improve consistency and reliability. Summation of the sub‐scores from each parameter yielded a total wound status score that ranged from 0 to 17. A photograph was taken at baseline and at week 4. Saltmarche ¹⁷ applied the PUSH along with planimetry to monitor the use of laser therapy for the healing of various chronic wound types including ulcers (n = 27) related to pressure, diabetes and venous insufficiency. The PUSH scores were correlated with the rate of healing for all wound types over the 9‐week trial. In another study of patients with venous ulcers, pressure ulcers, neuropathic ulcers, burns and scalds, skin tears, surgical wounds and traumatic wounds, Choi et al. ¹⁶ reported a strong agreement between the nurse's judgement of the wound healing status and PUSH scores; the kappa statistics was 0.97.

To assess protease activity in wound fluid, we used a foam swab (Puritan Medical, Guilford, ME, USA) and standardized technique to obtain wound fluid at baseline and at week 4. Once a wound fluid sample was collected, the foam swabs were frozen to −70°C as soon as possible. These swabs were then transported on dry ice to the laboratory for analysis. Once arrived in the laboratory, wound fluid was eluted from the foam swabs by submerging the swab and vigorously mixing in 110 μL assay buffer (50 mM Tris/HCl, pH 7·4 containing 10 mM calcium chloride dehydrate, 100 mM sodium chloride, 50 μM zinc chloride, 0.025% Brij 35 and 0.09% sodium azide). To ensure maximum recovery of fluid was obtained from the swab, the swab head was centrifuged in a 0·45 μm filter at 10 000 rpm for 2 min. The swab extracts were used immediately for protease testing. The activity levels of neutrophil‐derived elastase and MMP present in the wound fluid samples were measured spectrofluorimetrically using a substrate activity assay. The substrate comprised a short peptide synthesized to mimic the enzyme cleavage site and contained a fluorescent reporter group which was released upon hydrolysis; MeOSuc‐Ala‐Ala‐Pro‐Val‐7‐amino 4‐methyl coumarin (BaChem Ltd, UK). HNE activity was determined by measuring the rate of production of the fluorimetric compound, 7‐amino 4‐methyl coumarin. For measuring total MMP activity present in a biological sample, the fluorogenic substrate, Mca‐Lys‐Pro‐Leu‐Gly‐Leu‐Dpa‐Ala‐Arg‐NH2 (Enzo Life Sciences, NY, USA) was used. Activity was measured as the change in relative fluorescence units with time (RFU/min) and converted to mU HNE activity per 110 μL swab extract using a standard curve plotting RFU/min. HNE with known activities (mU) and MMP catalytic domain with known activities (U) were obtained from Innovative Research, Inc (Novi, MI, USA) for comparison. Each sample was tested in duplicate and the mean calculated. The substrate was prepared at a 10 mM‐stock concentration and diluted to a working concentration of 0.2 mM for HNE and 5 μM for MMPs in the assay buffer. The reaction mixture was combined in a microtitre well that comprised 5 μL wound fluid and 195 μL substrate (0.2 mM). The microtitre plate was read immediately at 450 nm (excitation 380 nm) and fluorescence monitored at timed intervals over the next 30 min using a microtitre plate fluorimeter; during this time the plate was kept at room temperature.

The selected measurement methods and tools have previously been validated and published in the literature. For the purpose of this study we also collected demographic information including age, gender, marital status, education, ethnic background, and other clinical information, including medications, dressing protocols and concurrent medical diagnosis, was obtained from the patients and/or patients' medical records. Local wound care was not standardized, individualized treatment was prescribed by the wound care team based on best practices.

2.2. Analysis

Data were analysed with the Statistical Package for Social Science (SPSS) version 29.0 (IBM®, Armonk, NY, USA). Descriptive statistics were computed to summarize the sample characteristics. We conducted correlation analysis to explore the strength and direction of relationships between variables. Multiple regression was modelled to explore if pain scores, stress levels and inflammatory responses could predict wound healing as a dependent variable. Wound healing was estimated by the differences in wound surface areas at baseline and at week 4. Beta coefficients (β) and associated confidence intervals (CIs) were calculated. Lastly, we dichotomized perceived stress into high or low stress levels by using the mean PSS score as the cut‐off. In logistic regression analysis, we tested the model including significant variables from correlational analysis as predictors and perceived stress as the outcome. Odds ratio was computed to determine the effect of these variables on the likelihood of high stress levels. The level of significance for all statistical tests was set at 0.05. The sample size was estimated based on Cohen criteria. ¹⁸ Anticipating a small to medium effect size (d = 0.5) based on results of a pilot study, with power = 0.80 and α = 0.05, the total sample size required to explore the relationship of stress, pain and wound healing was 27.

2.3. Results

A total of 32 individuals with chronic wounds participated in the study. The mean age of participants was 64. (SD = 15.9, range 25–90); 12 (40%) were married, and 15 (60%) were high school graduates. Almost one‐third of study participants (36.4%) had a medical history of diabetes, and 14 (14.4%) of the participants were on opioid analgesics. Other demographic characteristics are summarized in Table 1.

TABLE 1.

Demographic and clinical characteristics of the study participants.

Variables		Number (%)
Gender	Male	17 (53.1)
	Female	15 (46.9)
Marital status	Married	16 (50)
	Non‐married	16 (50)
Ethnicity	Caucasian	20 (69)
	Black	4 (13.8)
	Asian	4 (13.8)
	Native American	1 (3.4)
Education	High school or less	18 (72)
	Post‐high school	7 (28)
History of diabetes	Yes	14 (53.8)
	No	12 (46.2)
Wound types	Chronic surgical wounds	14 (56.2)
	Pressure injuries	5 (15.6)
	Leg ulcers	6 (18.8)
	Diabetic foot ulcers	1 (3.1)
	Other	6 (18.8)
Dressing frequency	Daily or more frequent	28

All participants had wounds, with a median duration of 48.5 days. The most common wound aetiologies were surgery (24.2%), amputation (18.2%) and pressure injuries (15.2%); located mainly on knees (31.3%), legs (25%) and the sacral area (19.8%). Patients received institutional standard wound care with 42.4% of the participants receiving daily wound care. Most wounds were cleansed with saline solution (72.7%) and treated with antimicrobial dressings (72.7%).

Median baseline wound size was 6.2 cm². PUSH mean score at the baseline was 11 ± 3.3 (Table 2).

TABLE 2.

Primary outcomes description.

Assessment	Baseline mean (SD)	Week 4 mean (SD)
PUSH score	11.3 (3.2)	1.24 (1.34)
Wound surface area	22.3 (39.9)	21.0 (36.8)
BPI pain severity score	12.8 (7.9)	10.7 (6.6)
BPI interference score	27.2 (19.5)	20.0 (2.8)
MPQ sensory score	9.4 (6.2)	8.9 (7.9)
MPQ affective score	2.4 (2.7)	1.6 (2.3)
LANSS score	5.3 (5.6)	4.6 (4.3)
PSS score	20.8 (5.4)	18.6 (5.1)
MMP (U/110 μL)	26.4 (58.6)	20.5 (25.7)
HNE (mU/110 μL)	42.4 (48.4)	51.3 (64.3)

Abbreviations: BPI, Brief Pain Inventory; HNE, neutrophil elastase; LANSS, Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale; MMP, metalloproteinases; MPQ, McGill Pain Questionnaire; PSS, Perceived Stress Scale; PUSH, Pressure Ulcer Scale for Healing; SD, standard deviation.

The average pain intensity score at baseline was 2.8 out of 10 indicating mild discomfort (standard deviation or SD was 2.2; ranging from 0 to 9). The mean worst pain score over the past week was 5.1 out of 10 (SD = 2.8; range = 0–10). The mean MPQ score was 9.5 out of a possible maximum score of 45 with most participants describing pain as aching (59.2%) and tender (76.1%). Mean PSS score was 14 with a standard deviation of 8.7. Other mean values are reported in Table 2.

Correlation analysis indicated pain severity was positively and significantly related to pain interference, MPQ scores, neuropathic pain and MMP levels (Table 3). PSS scores were correlated with pain interference and neuropathic pain as measured by the LANSS; the more interference and neuropathic symptoms reported by the participants the more stress they experienced. No significant relationship was found between MMP as an inflammatory marker and stress. None of the variables were correlated with wound surface area change. Other correlations are summarized in Table 3.

TABLE 3.

Pearson's correlation matrix between variables.

	BPI‐S	BPI‐I	MPQ‐S	MPQ‐A	PSS	MMP
BPI‐S		0.75*	0.62*	0.54*	0.29**	0.21**
BPI‐I	0.75*		0.63**	0.82*	0.63**	0.11
LANSS	0.38*	0.63**	0.61*	0.52*	0.39*	0.18

Abbreviations: BPI, Brief Pain Inventory; LANSS, Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale; MMP, matric metalloproteinases; MPQ, McGill Pain Questionnaire; PSS, Perceived Stress Scale.

^* p < 0.001;

^** p < 0.05.

Multiple regression analysis was used to assess BPI‐S, BPI‐I, MPQ‐S, MPQ‐A LANSS and PSS and MMP to predict wound healing as indicated by wound surface reduction. The total variance explained by the model was 34.5% F _(6,28) = 2.45, p = 0.05. BPI‐S (β = −2.2; 95% CI [−0.18, −3.6]), BPI‐I (β = −2.5; 95% CI [−0.4, −3.5]) and LANSS (β = 2.3; 95% CI [0.41, 3.4]) were the only statistically significant measures (all p < 0.05). Increases in pain severity and pain interference were associated with a decrease in wound surface areas. Logistic regression was used to determine the predictors for high or low perceived stress. The model contained six independent variables including BPI‐S, BPI‐I, MPQ‐S, MPQ‐A, LANSS and MMP was significant (chi square = 23.3 p < 0.001). The full model explained 64.7% (Nagelkerke R squared) of the variance in stress. The only significant variable that contributed to the stress levels was BPI‐I; Wald statistics was significant (critical value = 5.0 [df = 1]; p = 0.025). The odds ratio for the BPI‐I was 1.6 with a 95% confidence interval of [1.1, 2.4]. Results suggested that participants who experienced higher levels of pain interference were 1.6 times more likely to report high level of stress controlling for all other factor in the model.

3. DISCUSSION

According to the American Pain Society, pain is recognized as the fifth vital sign, a patient‐oriented outcome to benchmark quality patient care. ¹⁹ Despite the extensive attention towards pain management in clinical practice, wound related pain remains unacceptably high. Chronic wound related pain is often undervalued and undertreated. ²⁰ In a recently systematic review pooling data from 10 studies, Leren et al. ²¹ reported that 80% of persons living with venous leg ulcers experience mild to moderate pain at rest in between dressing changes. Tegene et al. ²² examined pain in 424 hospitalized patients with a variety of acute and chronic wounds, all study participants expressed mild‐to‐severe pain during wound management. In this study, 60.6% of participants experienced background pain at the time of assessment. Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. ²⁰ People living with chronic pain are prone to experiencing depression, anxiety and stress symptoms, the negative impact permeates all domains of functioning. However, there is much ambiguity in the relationship between pain, stress, inflammation and wound healing. In this study, we proposed that pain was related to stress, inflammation response and wound healing.

Stress and associated emotions can alter the pain experience. Consistent with our hypothesis, we found a significant relationship between stress and the extent to which pain impedes engagement with physical, cognitive, emotional and recreational activities, as well as sleep and enjoyment in life. The more severely pain interfered with daily activities, the higher the reported levels of stress. Pain research in the past decades suggests neuronal plasticity is integral to the initiation and maintenance of the chronicization of pain. Although the exact neurobiological mechanism remains elusive, stress regulates neuroplasticity by modulating the descending inhibition pain pathway that involved the rostral anterior cingulate cortex, hypothalamus, amygdala and periaqueductal gray and the endogenous opioid and dopamine systems producing hyperalgesia. ²³ Stress may also be intricately linked with anxiety and anticipatory pain, both of which are responsible for a nocebo effect that has been shown to intensify pain. ²⁴

Regression analysis indicated that pain severity, pain interference and neuropathic pain were significant predictors of wound surface area reduction. High pain intensity and pain interference with normal activities were associated with poor healing. Over the past few decades, accumulating evidence has elucidated the neuroendocrine hormonal mechanism of pain. Pain precipitates stress responses that involve cytokine and neuroendocrine activities compromising local blood flow and tissue oxygenation, immune response, inflammation and the regulation of metabolic processes. ²³ All together these physiological changes can impact on wound healing. Interestingly, increased neuropathic pain was a predictor of better healing. Perhaps as the wounds continue to improve, induction of axonal growth and sprouting, ectopic activity, synaptic remodelling and remyelination may amplify the response to stimuli and generate ectopic impulses.

We hypothesized that the relationship between pain and wound healing may be modulated by inflammatory response. Upregulation of inflammatory mediators has been implicated in a number of chronic pain syndromes by causing damage to nerve fibres and altering the central signalling pathway. Nociceptors become sensitized by inflammatory mediators (e.g., pro‐inflammatory cytokines, chemokines, nerve growth factor, bradykinin, prostaglandins) exhibiting increased hyperexcitability and hypersensitivity responses to normally painful stimuli (hyperalgesia) and even non‐painful innocuous stimuli (allodynia). ²⁵ In a chronic wound environment, analysis of wound fluid corroborates a superfluous and prolonged inflammatory response as indicated by high levels of cytokines (e.g., TNF‐α, IL‐1), proteases and MMPs. ²⁶ , ²⁷ , ²⁸ Based on a systematic review of existing evidence, wound related pain has been linked to elevated inflammatory biomarkers such as IL‐1β and Il‐6. ²⁹ However, we did not find any significant relationship between pain and inflammatory response. A variety of local treatments were used and some included dressing ingredients that possessed anti‐inflammatory properties. The type of treatments were not controlled for the analysis and this might have affected the results.

Recognizing the interrelationship between pain, stress and wound healing, pain management should be considered a priority taking into consideration both pharmacological and non‐pharmacological strategies. Pharmacological therapies may include a combination of agents that target nociceptive and/or neuropathic pain. While systemic medications are preferred for immediate relief from pain, topical analgesics has been demonstrated to be a viable option with minimal side effects for patients with wounds. Wound related pain is often precipitated by trauma and tissue damage, non‐pharmacological interventions focus on mitigating and preventing mechanical forces (e.g., pressure, friction and shear), chemical irritation, vascular damage (e.g., venous hypertension and arterial insufficiency) and excessive inflammation. Depending on the dressing material and adhesives, pulling of the dressing away from the fragile skin and detaching wound tissue along with congealed exudate, that is, embedded in the dressing microstructure, can be damaging to the wound and excruciatingly painful to patients. ³⁰ If excessive peel force is required, there is an appreciable risk for skin stripping and medical adhesive–related skin injury, as evident by persistent erythema and blisters, and skin tears. ³⁰ In a recent systematic review of reported outcomes and measurement instruments used in clinical research on bordered foam dressings in the treatment of complex wounds, Raepsaet et al. ³¹ identified pain as one of the key indicators. In addition to the desirable functions to promote faster wound healing and prevent infection, selection of dressings with an atraumatic interface have been recommended in many best practice documents as a strategy to limit skin damage/trauma with dressing removal and to minimize pain at dressing changes. Matsumura et al. ³² demonstrated that wound dressings coated with a silicone adhesive incurred significantly less detachment of the stratum corneum and regenerating epithelium, followed by other dressings coated with polyurethane, hydrocolloid and acrylic adhesives. Pain‐related education is a necessary step in interrupting the vicious stress pain cycle by debunking common misconceptions and myths that may provoke stress. ³³ Similarly, cognitive therapy that aims at altering stress by modifying attitudes, beliefs and expectations by exploring the meaning and interpretation of pain concerns has been successful in the management of pain. ³⁴ This may involve distraction techniques, imagery, relaxation or altering the significance of the pain to an individual. Patients can learn to envision pain as less threatening and unpleasant through positive imagery by imagining pain disappearing or by conjuring a mental picture of a place that evokes feelings and memories of comfort, safety and relaxation.

4. LIMITATIONS AND RECOMMENDATIONS

Several limitations should be considered when interpreting the findings of this study. A non‐probability sampling method was used. Many of the participants had surgical wounds and their experience of pain may not be generalizable to patients with a variety of chronic wounds. Pain and stress are complex experiences with multiple dimensions. Selection of the measurement tools to measure and collect data related to pain and stress may not have captured the complexity of these variables. Results may be affected by confounders including local treatment, wound chronicity and infection status. All measurements were obtained by the investigator who was not blinded to participants' responses to the questionnaires and wound measurements. The investigator may consciously or unconsciously view data, analyse outcomes or report results differently. In addition, selection of independent variables based on the strength of correlation coefficients between the variables for the regression model may also potentially create bias and problem with overfitting. Although it was hypothesized that pain perception influenced stress, one cannot exclude the possibility that stress may alter the experience of pain. In addition, this study was limited to the examination of the relationship between pain, stress and wound healing. Individual differences in personality, ability to regulate emotions, self‐efficacy, coping and anxiety sensitivity may influence the experience of pain and stress.

5. CONCLUSION

Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing. An understanding of this relationship will help in the treatment of chronic wounds. Dressings play a key role in creating an optimal environment for wound healing. In making decisions for selecting the most appropriate dressing, patients' experience and preferences are tantamount to wound characteristics. Deliberate effort is necessary to harness the unique perspectives and knowledge of individuals living with chronic wounds and to engage them as partners in co‐designing possible care options for dressing development. This study identified the significance of pain, an unmet need that requires that the clinicians, research scientists and industry should work collaboratively for a solution.

FUNDING INFORMATION

This research has been funded by the International Assocation for the Studies of Pain.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Woo K, González CVS, Amdie FZ, de Gouveia Santos VLC. Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing. Int Wound J. 2024;21(7):e14942. doi: 10.1111/iwj.14942

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.