The Impact of Wound‐Related Pain on Quality of Life, Psychosocial Well‐Being and Pain Beliefs in Individuals With Chronic Lower Limb Wounds

ABSTRACT

Chronic lower limb wounds are frequently accompanied by persistent wound‐related pain (WRP), which can impair physical functioning, emotional well‐being and coping capacity. Despite its prevalence, the multidimensional impact of WRP remains under‐recognised in routine wound care. This study examined the relationship of WRP on quality of life (QoL), physical health, psychosocial well‐being and pain‐related beliefs. A cross‐sectional survey of 105 patients attending an outpatient wound clinic was conducted. Participants were stratified by the presence or absence of WRP. Validated self‐report instruments assessed pain severity, physical function, emotional distress, depressive symptoms and coping strategies. Participants with WRP completed additional measures of psychological distress and pain catastrophising. Data were analysed using t‐tests, ANOVA and Spearman's correlations. Patients with WRP reported significantly higher pain severity (SF‐MPQ: 17.2 vs. 3.8, p < 0.001), greater physical disability (M‐RMDQ: 11.1 vs. 5.3, p < 0.001) and increased stress (DASS‐21: 4.7 vs. 2.4, p = 0.007). WRP was associated with maladaptive coping, including catastrophising and praying/hoping. Continuous pain was linked to higher catastrophising, particularly magnification and rumination. Younger patients demonstrated greater maladaptive pain beliefs. WRP in chronic wounds is a complex biopsychosocial phenomenon. Integrating pain management with psychological support and patient education may improve coping, reduce distress and healing outcomes.

Key Messages

• Wound management should shift from tissue‐centric to biopsychosocial care.

• WRP reduces QoL and may be linked to risks of dependency and reduced engagement.

• Psychological distress and maladaptive beliefs may lead to amplification of suffering of WRP.

• Wound management should be integrated with psychological support.

1. Introduction

Pain is a fundamental and universal human experience, yet it remains highly subjective, with substantial individual variance. In most cases, painful stimuli trigger protective responses such as avoidance, withdrawal or elimination of the insulting agent. Pain is a protective response, produced in the central nervous system when actual or potential threat of harm is detected, activating defensive responses that promote protection and enable escape from further danger [1]. In ageing populations, hard‐to‐heal wounds are often complicated by persistent wound‐related pain (WRP) that cannot be avoided, thus adversely affecting both physical and emotional well‐being of the patient.

WRP and its associated stress can also impair wound healing through complex physiological pathways. Activation of the sympathetic nervous system during stress stimulates adrenal medullary release of adrenaline and the HPA axis increases cortisol secretion, elevating respiration, heart rate and blood pressure [2]. Prolonged cortisol elevation suppresses immune function by inhibiting cellular migration, differentiation and proliferation [3]. This immunosuppression disrupts neutrophil and macrophage activity, leading to the accumulation of wound debris and contaminants. Cortisol‐induced vasoconstriction of small arterioles further compromises peripheral blood flow, nutrient delivery and tissue oxygenation [2]. Effective pain management and stress reduction may therefore mitigate inflammation, reduce infection risk and promote wound healing.

Beyond these physiological implications, chronic WRP substantially diminishes patients' quality of life (QoL), affecting both physical and emotional wellbeing. Wound pain often intensifies during essential daily activities such as walking, standing and stair climbing, limiting mobility and exacerbating emotional distress [4]. Up to 80% of patients with hard‐to‐heal wounds report significant pain even at rest [5], with many identifying pain as one of the most distressing symptoms of chronic wounds [6].

Recent research has increasingly highlighted the burden of pain among individuals with chronic wounds. Up to 3% of adults aged 60 and older experience reduced functional capacity and QoL due to chronic wounds [7]. Deficits in mobility, self‐care, capacity to perform usual activities and persistent discomfort are strong predictors of major amputation and mortality [8].

While wound healing remains the primary focus of clinical wound management, the subjective experience of pain and its broader psychosocial consequences are often under‐addressed. This study aims to explore the multidimensional impact of WRP, with a focus on physical functioning, emotional distress, coping strategies and pain‐related beliefs.

2. Materials and Methods

A single‐site cross‐sectional survey of people with chronic lower limb wounds was conducted to identify physical and psychosocial factors associated with hard‐to‐heal lower limb wounds with or without wound‐related pain.

2.1. Participants

A convenience sample of patients with hard to heal wounds were recruited from a metropolitan outpatient specialist wound management clinic in Australia. Eligible individuals attending the clinic during the data collection were invited to participate and those who consented completed the study measures. This sampling approach reflects the typical patient population of the clinic but may limit representativeness.

Potential participants were screened to determine their eligibility for inclusion into the study. Participants were required to be ≥ 18 years and have a lower limb wound of more than 3 months duration. Patients who were unable to understand and speak English fluently or who had cognitive impairment that limited their capacity  to understand and provide informed consent were excluded.

2.2. Data Measures and Collection

Prior to completing the survey, the Short Portable Mental Health Status questionnaire was completed to determine the cognitive status of the participants. Participants scoring 5 or more incorrect answers out of 10, indicating moderate to severe cognitive impairment, were excluded from the study [9].

Data collection for this survey was conducted as a participant interview prior to wound dressing changes. This was to ensure that the survey captured information about persistent WRP rather than pain caused by wound dressing changes.

Baseline assessments were collected via structured interview and included age, gender, education, living arrangements and wound characteristics. Wound‐related data comprised of duration and aetiology. Because the primary aim of the study was to examine the physical and psychosocial dimensions of WRP, only basic wound characteristics and core demographic information were collected.

Participants then completed a battery of validated self‐report psychometric instruments assessing pain status, affective distress, depressive symptoms and coping strategies. All instruments used in this study have established reliability and validity and are widely reported in peer‐reviewed publications. Pain characteristics and functional interference were assessed using the Short Form‐McGill Pain questionnaire (SF‐MPQ) [10, 11], the Short Form‐Brief Pain Inventory (SF‐BPI) [12, 13] and the Modified Roland–Morris Disability Questionnaire (M‐RMDQ) [14, 15]. Emotional and psychosocial domains were measured using the Depression Anxiety Stress Scales—Short Form (DASS‐21) [16], the brief Coping Strategies Questionnaire (CSQ) [17] and the Multidimensional Health Locus of Control (MHLC) [18]. The MHLC‐Form C was selected because it is ‘condition‐specific’ and appropriate for populations with established health conditions such as chronic wounds.

Participants who reported wound pain completed two additional instruments: the Pain Catastrophizing Scale (PCS) [19, 20] and the brief Survey of Pain Attitude (SOPA) [21, 22]. These instruments assess maladaptive pain (catastrophising) cognitions and pain‐related psychological disturbance, which are associated with increased pain morbidity in chronic pain syndromes [23, 24]. The description of the psychometric questionnaires is provided in the Appendix A.

2.3. Ethical Approval and Participant Consent

Human research ethics committee approval was obtained from the relevant institutions (ethics approval numbers: FHEC13/185 and H2013/05113) and complied with the guidelines set out in the Declaration of Helsinki. All participants provided written informed consent to participate in the study.

2.4. Analysis

Statistical analysis was undertaken using IBM SPSS version 24.0 (IBM Corp, Somers, NY, USA). Health‐related QoL and psychosocial data were calculated using absolutes (n) and expressed as means (SD) for normally distributed data. The categorical variables of patient characteristics, wound characteristics and presence of chronic pain (%) were recorded and chi‐square (χ ²) tests calculated to explore differences in frequencies between groups according to the presence of wound pain. Independent samples t‐tests were conducted to assess whether there were mean differences in QoL, disability, and psychosocial scores according to the presence of wound pain. One‐way analysis of variance with post hoc comparison tests was performed to explore mean differences between the nature of pain and subscales of psychosocial measures (coping strategies, beliefs, catastrophising and pain attitudes). Levene's test was used to test the homogeneity of variance, and when the variance assumption was violated, the Welch test and the Games‐Well post hoc tests were used.

3. Results

3.1. Patient Characteristics

A total of 105 participants were recruited of whom 54% were females. Ages ranged from 32 to 91 years (μ = 71 years) with 71% aged 65 and older, reflecting a predominantly older population. Wound duration varied across participants, with a substantial proportion experiencing long‐term wounds; 57.1% of those with WRP and 62.9% of those without pain had wounds persisting for more than 24 months. The remaining participants had wounds lasting less than 24 months, indicating that chronicity was common across both groups regardless of pain status. Living arrangements differed slightly between groups. Among the participants with WRP, 37.1% lived alone and 58.6% lived with a partner or carer, compared with 40.0% and 32.8%, respectively, in the no‐pain group. A small proportion resided in supported care facilities (4.3% with WRP, 2.9% without pain) (Table 1).

TABLE 1.

Participant demographic and clinical characteristics.

Variables		Pain, n = 70 (66.7)	No pain, n = 35 (33.3)
Gender	Male	33 (47.1)	15 (42.9)
	Female	37 (52.9)	20 (57.1)
Wound duration	More than 24 months	40 (57.1)	22 (62.9)
	Less than 24 months	30 (42.9)	13 (37.1)
Living arrangements	Living alone	26 (37.1)	14 (40.0)
	With partner or carer	41 (58.6)	20 (32.8)
	Supported residential care	3 (4.3)	1 (2.9)
Wound aetiology	Venous	45 (64.3)	18 (51.4)
	Ischaemic	4 (5.7)	7 (20.0)
	Diabetic	3 (4.3)	3 (8.6)
	Vasculitic	5 (7.1)	0 (0)
	Mixed	0 (0)	4 (11.4)
	Pyoderma	6 (8.6)	1 (2.9)
	Malignant	1 (1.4)	1 (2.9)
	Other	6 (8.57)	1 (2.86)

Note: Values are expressed as n (%).

Sixty‐eight participants (68%) reported they had WRP in response to the question ‘Do you have wound pain?’ and 67% reported pain most days over the past 3 months. When asked to describe the nature of their pain, the proportion reporting pain increased to 72%. Pain was categorised as brief, intermittent and continuous; 12 participants (11%) reported brief pain, 27 (26%) intermittent pain and 37 (35%) continuous pain. Venous wounds were the most common aetiology (60%). All wound types, except for mixed aetiology wounds, were reported as painful.

3.2. Cohort Groupings

Participants were categorised into two groups: those experiencing WRP most days over the past 3 months (n = 70) and those without pain (n = 35). Pain impact data were collected using a variety of validated scoring tools to provide a comprehensive assessment of pain and its impact on QoL and physical functioning.

3.3. Impact on Quality of Life and Physical Well‐Being

Participants with WRP reported significantly higher scores on the SF‐MPQ (sensory: μ = 13.1 vs. 3.2, p < 0.001; affective: μ = 4.4 vs. 0.6, p < 0.001; total: μ = 17.2 vs. 3.8, p < 0.001). SF‐BPI scores indicated greater interference in general activity, mood, sleep and walking ability (all p < 0.01). M‐RMDQ scores revealed higher disability in the pain group (μ = 11.1 vs. 5.3, p < 0.001) (Table 2).

TABLE 2.

Impact on quality of life.

Questionnaire	Pain, μ (SD)	No pain, μ (SD)	p a
SF McGill Questionnaire b
Sensory	13.1 (7.3)	3.2 (4.1)	< 0.001
Affective	4.4 (3.7)	0.6 (1.9)	< 0.001
Total	17.2 (10.3)	3.8 (5.3)	< 0.001
Brief pain inventory c
General activity	4.3 (3.6)	2.2 (3.0)	0.003
Mood	4.2 (3.5)	1.2 (2.3)	< 0.001
Normal work	3.9 (3.9)	2.2 (3.4)	0.022
Relations with other people	2.5 (3.4)	1.1 (2.3)	0.027
Sleep	3.9 (3.6)	1.6 (2.9)	0.001
Enjoyment of life	4.6 (3.7)	2.5 (3.3)	0.004
Walking ability	4.2 (3.7)	2.2 (3.0)	0.005
Mobility (Roland–Morris) d	11.1 (6.1)	5.3 (6.0)	< 0.001

Note: Values are expressed as mean (SD).

^a Analysis evaluated using an independent samples t‐tests.

^b SF‐MPQ: the higher the score the greater the pain experience. Sensory score range 0–33, affective score range 0–12, total pain experience score range 0–45.

^c BPI: the higher the score the greater the pain or interference of pain with activities. Score range 0–10.

^d M‐RMDQ: the higher the score the greater the limitation of the activity and severity of physical disability. Score range 0–24.

3.4. Psychosocial Impact

Depressive symptoms were reported on the DASS21 by 39% of participants with WRP compared with 31% of those without pain. Participants with WRP also recorded higher mean scores across all three DASS21 subscales (depression, anxiety and stress). Stress scores were significantly higher in the pain group (μ = 4.7 vs. 2.4, p = 0.007), as were overall psychological distress scores using the total DASS21 score (μ = 12.1 vs. 6.5, p = 0.016). Coping strategies differed significantly on the CSQ, with the pain group reporting greater use of diverting attention (μ = 2.2 vs. 1.1, p = 0.004) catastrophising (μ = 2.4 vs. 1.2, p = 0.002), praying and hoping (μ = 2.7 vs. 1.4, p = 0.001), and increased behavioural activities (μ = 3.0 vs. 1.1, p < 0.001). MHLC scores showed some variation between groups, but none reached statistical difference (Table 3).

TABLE 3.

Psychological impact.

Questionnaire	Pain, μ (SD)	No pain, μ (SD)	p a
DASS21 b
Depression	1.5 (0.9)	1.2 (1.0)	0.163
Anxiety	1.1 (0.9)	1.0 (0.9)	0.608
Stress	4.7 (4.2)	2.4 (3.9)	0.007
Total	12.1 (11.2)	6.5 (10.3)	0.016
Coping strategies c
Diverting attention	2.2 (1.9)	1.1 (1.6)	0.004
Reinterpreting	0.9 (1.3)	0.5 (1.1)	0.128
Catastrophising	2.4 (1.9)	1.2 (1.6)	0.002
Ignoring	2.3 (1.7)	2.7 (1.7)	0.203
Praying and hoping	2.7 (1.8)	1.4 (2.0)	0.001
Coping	2.9 (1.8)	2.1 (1.8)	0.028
Increasing behaviour activities	3.0 (1.9)	1.1 (1.3)	< 0.001
Health locus of control d
Internal	20.9 (8.8)	19.2 (8.1)	0.352
Chance	19.5 (7.4)	17.0 (7.6)	0.102
Powerful others	28.2 (5.6)	29.1 (5.5)	0.430
Doctors	14.7 (3.2)	15.1 (2.9)	0.607
Other people	13.9 (4.0)	14.3 (3.7)	0.583

Note: Values are expressed as mean (SD).

^a Analysis evaluated using independent samples t‐tests.

^b DASS21 = Depression, Anxiety and Stress Scale21 (higher values indicate increased severity of the emotional state; range 0–21 points).

^c The greater the value, the more frequently the strategy is used to cope with pain. Scores range from 0 to 6.

^d The greater the value, the more the belief of who is in control of their wound.

3.5. Beliefs and Pain Catastrophising

The PCS and SOPA were administered only to participants who reported wound pain (Table 4). Younger participants (< 64 years) reported higher scores for all subscales of catastrophising measures, with significant differences found in magnification (p = 0.014) and helplessness (p = 0.041). Although SOPA scores were also higher in younger participants, no age‐related differences reached statistical significance.

TABLE 4.

Beliefs and pain catastrophising between age and gender.

Questionnaire	64 and younger, μ (SD)	65 and older, μ (SD)	p a	Male, μ (SD)	Female, μ (SD)	p a
Pain catastrophizing scale
Rumination (max. score 16)	5.4 (5.3)	3.9 (4.6)	0.129	4.8 (4.8)	4.0 (4.9)	0.353
Magnification (max. score 12)	3.0 (3.2)	1.5 (2.3)	0.014	2.6 (3.1)	1.5 (2.2)	0.040
Helplessness (max. score 24)	6.3 (6.0)	3.7 (5.6)	0.041	4.4 (5.3)	4.7 (6.3)	0.796
Total (max. score 52)	14.7 (13.5)	9.1 (11.4)	0.040	11.8 (12.1)	10.2 (12.6)	0.483
Survey of pain attitudes (max score 4 per subscale)
Adaptive beliefs
Pain control	1.9 (1.5)	1.5 (1.4)	0.235	1.8 (1.3)	1.5 (1.5)	0.283
Emotion	1.6 (1.4)	1.5 (1.2)	0.081	1.4 (1.4)	1.3 (1.3)	0.653
Maladaptive beliefs
Disability	1.6 (1.5)	1.2 (1.4)	0.150	1.3 (1.37)	1.3 (1.4)	0.915
Harm	1.8 (1.4)	1.4 (1.3)	0.186	1.6 (1.3)	1.5 (1.4)	0.746
Medication	1.9 (1.4)	1.6 (1.5)	0.340	1.8 (1.5)	1.7 (1.5)	0.775
Solicitude	1.6 (1.4)	1.2 (1.3)	0.127	1.3 (1.3)	1.4 (1.4)	0.574
Medical care	1.9 (1.4)	1.7 (1.5)	0.505	1.9 (1.5)	1.6 (1.4)	0.255

Note: Values are expressed as mean (SD).

^a Analysis evaluated using an independent sample t‐test.

PCS total scores did not differ between genders; however, males reported higher magnification levels than females (p = 0.04). SOPA subscale scores reported no significant gender differences. Analysis by pain type (brief, intermittent and continuous) indicated stronger beliefs in medication efficacy among those with continuous pain (p = 0.006) but found no differences across PCS catastrophising subscales (Table 4).

3.6. Cognitive Behaviour and Nature of Pain

The CSQ and MHLC‐C were used to conduct additional statistical analysis to explore the relationship between psychological processes and painful chronic wounds.

Participants with continuous pain were significantly more likely to use ‘catastrophising’ strategies than those with no pain. The coping strategy of ‘behaviour activity’ was also higher among participants with intermittent and continuous pain compared to those with no pain. MHLC‐C scores showed no significant differences across subscales or pain type categories.

4. Discussion

This study demonstrates the psychological and behavioural burden associated with WRP in individuals living with chronic wounds. Participants reporting wound pain showed higher levels of psychological distress, reflected in significantly elevated total DASS21 scores, and reinforced by greater mood disturbance on the BPI. These findings align with existing literature suggesting that pain is not merely a physical symptom but a multidimensional experience that exacerbates emotional burden and impairs overall well‐being [25].

Furthermore, our study found that depressive symptoms were reported by 39% of participants with WRP compared to 31% with no pain, consistent with existing evidence that around 30% of people with chronic wounds experience anxiety or depression, three times the rate seen in the general population [26]. This highlights the need to incorporate mental health screening in wound care, particularly as many patients remain reluctant to disclose psychological distress unless asked directly.

Patients with wound pain demonstrated a greater reliance on coping strategies in general, as reflected in the CSQ scores. Some strategies, such as diverting attention and increased behavioural activation, may represent adaptive attempts to regain a sense of control or distract from pain [27].

Conversely, the prominence of maladaptive strategies such as catastrophising is concerning given its association with poorer pain outcomes and delayed healing [28]. Individuals who engage in catastrophic thinking have more difficulty in disengaging from pain [29]. Findings from the PCS further highlight this pattern where younger patients and males reported higher levels of catastrophising, especially in magnification and helplessness domains. Magnification reflects perceiving pain as highly threatening, which is associated with increased pain intensity and reduced function, while helplessness indicates a perceived inability to cope with pain. Chronic wounds are associated with stigma related to ageing, frailty and dependence [30] which may be particularly challenging for younger individuals to reconcile. This group may benefit from targeted support such as clear, inclusive education about wound care and expected healing trajectories to improve understanding and promote self‐efficacy.

Gender patterns in pain reporting and wound‐related experiences have been described in previous studies, with some evidence suggesting that men and women encounter wound‐related stigma differently [31]. Sociocultural influences have also been proposed as one factor contributing to differences in how pain is expressed [32], although the extent to which these influences operate in wound care populations remains unclear.

In our cohort, a higher proportion of women reported WRP, consistent with broader findings. Males, however, recorded higher magnification scores on the PCS. Given the relatively small sample, this observation should be interpreted cautiously and considered hypothesis‐generating rather than a definitive demographic pattern. It indicates a potential area for further investigation into gender‐related variation in WRP, but larger studies are needed to determine whether this difference is consistent or clinically significant.

The SOPA was used to identify beliefs and attitudes related to WRP that may influence how individuals engage with their wound care [17]. Although SOPA scores did not differ significantly by gender or age, younger participants tended to endorse more maladaptive beliefs. Given the sample size, this pattern should be interpreted cautiously rather than as a definitive age‐related effect. In the context of significant differences observed on the DASS‐21 and BPI mood subscales, these findings suggest that younger individuals with chronic wounds may warrant further investigation to determine whether targeted psychological support could be beneficial.

Physiologically, chronic psychological stress has well‐documented consequences for wound healing [2]. Elevated cortisol and pro‐inflammatory cytokines can impair immune function and tissue repair, creating a feedback loop wherein pain and stress perpetuate delayed healing [33]. This biological interplay highlights the importance of considering psychological factors as part of comprehensive wound care.

An area for future research arises from the observation that 22 of the 60 participants with wounds persisting longer than 24 months reported no pain. Ordinarily, pain triggered by an acute injury diminishes as healing progresses; however, when noxious stimuli persist, as in chronic wounds, ongoing pain and the potential development of chronic pain would generally be expected due to central and peripheral sensitisations to the nervous system [34, 35]. While research has explored the predictive factors for chronic pain related to other conditions, there is a clear gap exploring this for people with chronic wounds.

QoL is markedly diminished in patients with persistent pain [36]. Poor sleep, reduced physical functioning and emotional distress were prevalent within this cohort, and many participants appeared to accept pain as an inevitable aspect of their condition. This resignation may hinder proactive pain management and underscores the need for patient education and empowerment.

Living arrangements emerged as a potentially influential factor. While living alone was common across both groups, those with pain were more likely to live with a partner or carer. This pattern may reflect increased care needs or reduced functional independence among individuals with pain. Although living alone did not directly correlate with pain prevalence, it may contribute to psychological stress and reduced coping capacity, both of which are known to exacerbate pain perception and impede healing.

Taken together, these findings emphasise the complex interplay between psychological distress, coping mechanisms, beliefs and social context in the experience of WRP.

Healthcare providers should remain mindful of these factors and offer education and, when appropriate, early referral to psychological supports that can strengthen adaptive coping. Interventions that address both the emotional and social dimensions of pain, such as cognitive‐behavioural therapy, enhanced social support, and patient‐centred education, may help improve outcomes for this vulnerable population.

4.1. Limitations

This study has several limitations that should be considered when interpreting the findings. First, the cross‐sectional design precludes causal inference between WRP and psychological distress; the findings indicate associations only. Longitudinal studies are needed to assess changes over time and the directionality of these relationships. Second, this is a convenience sample from a single metropolitan outpatient wound clinic; as such, it may not reflect individuals receiving wound care in other clinical settings, including community services, hospital units and rural clinics. Third, the sample size may limit generalisability, particularly across diverse demographic groups. Pain experiences can also be culturally influenced, and there can be biological contributors to pain which may be more prevalent in specific ethnic populations [37]. Further research involving people from non‐English speaking backgrounds would help enhance understanding of chronic WRP in culturally diverse groups. Fourth, self‐reported measures may be subject to bias, including underreporting or overreporting of pain and emotional symptoms. Finally, while living arrangements were explored, other social determinants of health such as socioeconomic status, access to care and cultural factors [38, 39, 40], were not fully accounted for and may influence both pain experience and coping capacity.

4.2. Future Research Recommendations

This study highlights several priorities for future research to advance understanding of the psychosocial relationship of WRP. First, research should clarify the interaction between biomedical wound factors and psychosocial variables. Specifically, studies should examine how mechanical and tissue‐related inputs to the pain system (e.g., ischaemia, infection, debridement, dressing practices) interact with cognitive, emotional and social factors to either protect against or contribute to acute pain and its transition to chronicity.

Second, longitudinal research is needed to explore the relationship between wound duration, psychological distress and pain severity. Clarifying these relationships may reveal modifiable intervention targets for intervention, particularly in the early phases of non‐healing, where timely psychosocial support may attenuate pain escalation and improve overall recovery trajectories. Finally, it is important to identify the characteristics of patients who effectively use adaptive coping strategies and to determine how clinicians can better support those who struggle to do so.

Together, these priorities support a more integrated biopsychosocial approach to WRP that may improve both clinical and patient‐reported outcomes.

5. Conclusions

WRP in chronic lower limb wounds is a complex, multidimensional experience that extends beyond tissue pathology to encompass physical, emotional and cognitive domains. The findings of this study reinforce the necessity of recognising WRP as more than a sensory phenomenon and highlight the influence of psychological and social factors on pain perception and recovery. Addressing these dimensions within routine wound care is essential.

Integrating mental health support, targeted patient education and strategies that strengthen coping and self‐efficacy may help mitigate distress and reduce the risk of pain chronification. Collectively, these findings support a shift from a predominantly tissue‐focused model of care towards a comprehensive biopsychosocial framework. Such an approach is essential to reduce suffering and improve QoL for individuals living with chronic WRP.

Funding

The authors have nothing to report.

Ethics Statement

Human research ethics committee approval was obtained from La Trobe University and Austin Health (ethics approval numbers: FHEC13/185 and H2013/05113) and complied with the guidelines set out in the Declaration of Helsinki.

Consent

All participants provided written informed consent to participate in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A. Summary of Survey Tools

Quality of Life and Physical Functioning Scores

1. Short‐Form McGill Pain Questionnaire (SF‐MPQ) [10]

   • Measures both the sensory and emotional dimensions of pain.
   • Includes 15 word descriptors—11 referring to sensory quality of pain and 4 referring to affective dimension of pain—plus a Present Pain Intensity (PPI) scale and a Visual Analog Scale (VAS).
   • The higher the score the greater the pain experience. Sensory score range 0–33, affective score range 0–12, total pain experience score range 0–45.
2. Short‐Form Brief Pain Inventory (SF‐BPI) [12].

   • Evaluates pain severity and its interference with daily functions such as mood, walking, work and sleep.
   • Two main domains—pain intensity and pain interference—rated on a 0–10 scale.
   • The higher the score, the greater the interference with activities.
3. Modified Roland–Morris Disability Questionnaire (M‐RMDQ) [14, 15]

   • Purpose: Assesses physical functioning and disability related to low back pain. This was modified to refer to the wound.
   • Structure: A self‐report questionnaire with statements about physical limitations due to back pain. This was modified to refer to the wound.
   • Scoring: Patients check items that apply to them with the score range 0–24
   • The higher scores indicate greater disability.

Psychosocial Measures

1. Depression Anxiety Stress Scales—Short Form (DASS‐21) [16].

   • Purpose: Measures the severity of symptoms related to depression, anxiety and stress over the past week.
   • Structure: 21 items divided into 3 subscales (7 items each)
   • Scoring: Each item rated on a 0–3 scale; subscale scores are doubled to align with the original DASS‐42. Severity is categorised from normal to extremely.
2. Brief Coping Strategies Questionnaire (CSQ) [41].

   • Purpose: Evaluates cognitive and behavioural coping strategies used in response to pain or stress.
   • Structure: The brief version contains 14 of the 50‐item self‐report questionnaire designed to assess coping strategies broken down into six subscales:

     • ○
       Catastrophizing
     • ○
       Reinterpreting pain sensations
     • ○
       Ignoring pain
     • ○
       Praying or hoping
     • ○
       Coping self‐statements
     • ○
       Increasing activity
   • Scoring: a 7‐point scale, each item can be rated from ‘0 = never do that’ to ‘6 = always do that’. Respondents rate how often they use each strategy; scores reflect reliance on adaptive vs. maladaptive coping.
   • It measures three constructs: conscious cognitive coping attempts, confidence is controlling and decreasing pain and diverting attention in non‐painful activities [42].
3. Multidimensional Health Locus of Control‐Form C (MHLC‐C) [18]

   • Purpose: Assesses beliefs about control over health outcomes.
   • Structure: 18‐item self‐report questionnaire.
   • Three primary dimensions:

     • ○
       Internal: Belief that one's own actions determine health.
     • ○
       Powerful Others: Belief that health professionals or others control health.
     • ○
       Chance: Belief that health is determined by fate or luck.
   • Scoring: Items rated on a Likert scale; rated on a 6‐point Likert scale (1 = strongly disagree to 6 = strongly agree). Higher scores indicate stronger belief in that locus.

Pain Beliefs and Catastrophising

1. Pain Catastrophizing Scale (PCS) [20]

   • Purpose: Measures the extent of catastrophic thinking related to pain, which can amplify pain perception and emotional distress.
   • Structure: 13‐item self‐report questionnaire rated on a 5‐point Likert scale (0 = not at all to 4 = all the time).
   • Scoring: Total score ranges from 0 to 52; scores above 30 indicate clinically significant catastrophising.
2. Brief version Survey of Pain Attitudes (SOPA)—(2 items per scale) [22].

   • Purpose: Assesses beliefs and attitudes about pain that influence coping, adjustment and treatment outcomes.
   • Structure: Seven domains (control, disability, harm, emotion, medication, solicitude and medical cure)
   • Brief version contains 14 of the 57‐item questionnaire rated on a 5‐point Likert scale.
   • Scoring: Items can be rated with ‘0 = very untrue for me’ to ‘4 = very true for me’. Provides T‐scores and percentiles; identifies clinical, subclinical and adaptive ranges.

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.