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Time to get serious about assessing – and managing – psychosocial issues associated with chronic wounds

Alexander, Susan J.

Current Opinion in Supportive and Palliative Care: March 2013 - Volume 7 - Issue 1 - p 95–100
doi: 10.1097/SPC.0b013e32835bf2a3
WOUND MANAGEMENT IN ADVANCED ILLNESS: Edited by Vincent Maida
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Purpose of review This article comprises a review of the literature published during the period January 2011 to June 2012 on the topic of the psychosocial impact of wounds and strategies to manage them.

Recent findings There is a growing discussion of the reciprocal link between psychological influences and wound healing. Although the mechanisms underlying these influences are not well understood, evidence from the reviewed literature adds to the existing body of evidence demonstrating that negative psychological states can impair immune function and wound healing. Despite this recognition, there are still few studies that provide strategies to address the identified psychosocial issues associated with wounds, particularly those of chronic duration.

Summary A wide range of psychosocial factors likely to be associated with a wound have been identified. The importance of understanding the nature and extent of their impact is illustrated by the patients’ experiences of living with a chronic wound which they rate as serious as cancer or myocardial infarction. Although there is currently limited evidence on which to base management strategies, it is recommended that interventions should commence with a comprehensive individualized assessment which can then inform the development of an appropriate management plan that includes the identified psychosocial issues.

University of Western Sydney, Penrith, New South Wales, Australia

Correspondence to Dr Susan J. Alexander, BHlth (Nursing) (Honours), GCTE, PhD, RN, MRCNA, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. Tel: +61 2 9685 9412/9631 3692; mobile: +61 0400 578 641; e-mail: susan.alexander@uws.edu.au

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INTRODUCTION

Despite the growing recognition of the wide range of psychosocial factors associated with chronic wounds, the majority of the literature still discusses the management of wounds, rather than the management of patients with wounds. This difference in nomenclature might seem minor, but it probably helps to explain why psychosocial issues are still not routinely included in management plans, even though they are widely recognized as having a significant reciprocal role in wound healing. Despite this recognition, there remains a paucity of research published on the mechanisms through which psychosocial factors influence and are influenced by chronic wounds. There has been some research into the influence of psychosocial factors on acute wounds that can inform wound healing in general, but it cannot adequately address the healing and nonhealing of chronic wounds that are typically of longer duration and greater burden, and therefore more likely to result in the reciprocity of influence referred to in the vernacular as a ‘vicious circle’ or ‘negative spiral’. So, at this point in time, it is known that psychosocial factors influence and are influenced by wound healing, but possibly as a result of not fully understanding the mechanisms of those influences, there are limited strategies to address them.

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LITERATURE REVIEW

Search terms ‘chronic wound’ and ‘psychosocial’ were submitted to six databases (Medline, CINAHL with Full Text, Cochrane, Health Source: Nursing/Academic, Informit, and University of Western Sydney Library) and the website for the journal Wounds. The search was limited to articles in English published between January 2011 and June 2012. Reference lists of all selected articles were also reviewed to source other relevant articles. Although falling outside the time period, the article by Pragnell and Neilson [1▪▪] was included because it provided a case study that richly illustrated the lived experience of having a chronic wound and the associated psychosocial issues.

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PSYCHOSOCIAL FACTORS ASSOCIATED WITH CHRONIC WOUNDS

Despite the lack of research into the mechanisms underpinning the reciprocal link between psychosocial factors and chronic wounds, there has been recognition of a wide range of psychosocial factors, both direct and indirect, associated with chronic wounds: reduced quality of life (QOL); anxiety; depression; suicidal ideation; blame; guilt; hopelessness; sleep disturbances; stress; negative affect; embarrassment; helplessness; fatigue; irritability; negative body image; concentration problems; anhedonia; environmental restriction; social isolation; stigma; frustration; inability to perform work-related tasks and activities of daily life (ADL); reduced independence; financial difficulties (reduced income, increased expenditure); impaired mobility; appearance of wound; oedema; malodour; pain (both at wound site and during wound treatment regimes); wound itch; reduced physical activities; clothing and footwear restrictions; disgust; low self-worth and self-esteem; suddenness and unexpectedness of having to deal with a chronic wound; role changes (both patient and family); fear; uncertainty; ‘merry-go-round’ of time-consuming appointments; failed treatments; sympathetic musculoskeletal problems; striving to remain positive and upbeat for the sake of loved ones; possible alopecia; high cost to patient and healthcare system; discomfort, difficulty in application and expense of dressings [1▪▪,2▪▪,3▪,4▪,5,6▪,7–9,10▪▪,11▪▪,12▪,13▪▪,14▪,15▪▪–18▪▪,19▪,20,21▪,22,23▪].

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WHY PSYCHOSOCIAL FACTORS ARE IMPORTANT

Looking at the bigger picture of psychosocial issues and chronic illness, Eric Cassell was one of the first researchers to recognize the multidimensional nature of illness-related suffering. In his 1991 book The Nature of Suffering and the Goals of Medicine, he highlighted the reciprocity of influence between patient and illness. That is, all of the dimensions of a person influence, and are influenced by, an illness. Therefore, it might be considered elementary that treatment of that illness should similarly be multidimensional. However, in contemporary medicine, this is often not the case, and there is an enduring preference amongst clinicians for objective measures, ‘facts’ and certainty with a concomitant disinclination to acknowledge the subjectivity and uncertainty that characterize the complex individuals in the vortex of a chronic illness.

From the patients’ perspective, however, the importance of understanding the role of psychosocial factors in chronic wounds is clearly illustrated by their own ratings of their experiences. Londahl et al.[14▪] investigated the experiences of patients with diabetic foot ulcers (DFUs) and reported ratings similar to other serious conditions such as breast cancer and recent myocardial infarction. Garcia-Morales et al.[6▪] also investigated the experiences of patients with diabetes and found DFU to have a more negative impact than other complications of diabetes, including unilateral amputation of a lower limb, and to be more negative than breast cancer. Therefore, because healthcare professionals provide care for ‘patients with wounds’, effective care will be about so much more than just finding an appropriate wound dressing. The most expensive wound dressing will not heal a wound if there are underlying issues (biological and psychosocial) that are influencing the wound that are not also addressed at the same time.

Ample research presents compelling evidence of a statistically significant reciprocal link between disordered mood (psychological stress and other behavioural factors) and immune system functioning with consequent adverse health outcomes, including poor wound healing [1▪▪,2▪▪,4▪,5,10▪▪,11▪▪,12▪,15▪▪–18▪▪,19▪], dysregulated inflammatory responses, and susceptibility to infectious diseases through poor response to vaccines and disrupted immune control of latent viruses [17▪▪]. A fully functioning immune system is essential if wound healing is to be timely and progress successfully through the complex healing cascade, but stress impairs immune functioning [19▪] and may interfere with the initial inflammatory response, preventing progression to the proliferative phase and so delaying wound healing [17▪▪]. In what was described by Upton and South [12▪] as a ‘vicious circle’, the presence of psychological stress may impede wound healing which may exacerbate psychological stress which may further impair healing, and so on in a negative spiral. The spiral effect is illustrated by the health-related quality of life (HRQOL) scores of patients with wounds of longer duration (12 months) which were significantly lower than the patients with wounds of 2 months duration [6▪].

There is some research demonstrating positive impact on psychosocial status following successful wound interventions. Londahl et al.[14▪] conducted a study into the potential for hyperbaric oxygen therapy to improve the HRQOL of patients with DFU. They found that patients whose ulcers had healed recorded significant improvements in mental health summary score, social functioning role and role limitations because of physical and emotional health.

Conversely, a number of studies have demonstrated the deleterious effects on wound healing of a variety of stressors, including childhood sexual abuse; marital stress and divorce; spousal bereavement; caring for a relative; disability; unemployment; job interviews and exam stress among college students [17▪▪,18▪▪,19▪]. It appears that even the quality of the marital stress influenced wound healing. The wounds of couples whose interactions were more hostile healed at only 60% of the rate of couples whose interactions were less negative [18▪▪]. Gouin and Kiecolt-Glaser [18▪▪] presented the results of a study showing that participants with anger management difficulties were 4.2 times more likely to be slow wound healers than those with good anger management. They also reviewed a number of studies demonstrating that greater stress prior to surgical procedures worsened patient outcomes, including longer hospitalization, poorer wound healing and greater incidence of postoperative complications. Authors have also raised the possibility that psychological stress can lead to unhealthy behaviours that might also impair wound healing, including smoking, alcohol abuse, decreased physical activity, poor nutrition and altered sleep [4▪,12▪,17▪▪,18▪▪,19▪].

Research has also demonstrated a significant link between psychosocial factors and the risk of recurrence and median time to recurrence for participants with ulcers. A study by Finlayson et al.[4▪] showed that patients in the two highest quartiles for social support were 12.9 times less likely to experience ulcer recurrence than those in the lowest quartiles. Time to recurrence for patients with higher at-risk depression scores was 31 weeks, compared with 39 weeks for participants with lower scores. A number of authors commented on the higher rates of depression amongst patients with chronic wounds, but most did not consider whether the depression was an effect of the chronic wound or a contributing factor. Given the evidence for reciprocity considered in this review, it appears likely that it is both.

Despite the well recognized link between psychosocial factors and wound healing and nonhealing, there are few studies that have attempted to quantify the incidence of mood disorders in patients with chronic wounds. In one study by Upton et al.[11▪▪], practitioners (n = 39) stated their belief that 50–75% of their patients with chronic wounds also had associated mood disorders. However, they also noted that most of their patients were not receiving treatment for mood disorders. Earlier studies have reported rates of depression ranging from 25 to 27% and anxiety ranging from 26 to 30%, but more large-scale studies are required.

One shortcoming of most of the research to date is that it has evaluated the effects of psychological stress on acute wounds inflicted in a controlled setting with a predictable healing trajectory. Typically, the main variable being measured is that of time to healing – a variable not always applicable in the case of chronic wounds. One of the reasons for the minimal investigation into the impact of psychological stress on chronic wounds is the uncontrollable nature of the size and healing processes characteristic of chronic wounds. Not least because of the finding by Upton et al.[11▪▪] that mood disorders were 1–2 times more prevalent in chronic wounds than acute, it is reasonable to doubt that psychological factors affecting acute wound healing will be the same as those affecting chronic wound healing. Therefore, there is a definite need for more research into the psychosocial factors associated with chronic wounds and how they might be influencing or being influenced by wound healing and nonhealing.

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THE BIOLOGICAL AND PSYCHOSOCIAL INTERFACE

It is not the intention of this article to discuss the biological mechanisms in detail as the focus is on psychosocial issues (see Gouin [17▪▪] for a good discussion of the biological mechanisms and the mechanics of differing levels influencing wound healing, together with a good review of research demonstrating the link of these elements between psychological stress and wound healing). Suffice to say that psychological stress affects and is affected by many of the elements present in chronic wounds, including oxytocin, vasopressin, epinephrine, catecholamines, cortisol and other glucocorticoids and leukocytes [2▪▪,18▪▪].

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INTERVENTIONS

The current review differed little from the previous literature reviews that have demonstrated that psychosocial issues are typically included in assessment, but then overlooked in the subsequent discussion on the management of patients with chronic wounds.

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Assessment

As with any treatment plan, the first step must be comprehensive and individualized assessment of the patient, not just the wound. The importance of holism in assessment and management was highlighted by McKenzie [20], who declared a disinclination to use the term ‘wound care’ because it focussed on ‘skin alteration’ rather than the patient as a complex entity, including their psychosocial condition. At times, it may be more appropriate to aim for wound palliation, rather than healing. In these instances, rather than expending energy and resources on a wound that is unlikely to heal, an individualized assessment might indicate that a less aggressive approach aimed at managing pain, malodour and exudate might do more for a patient's QOL than aggressive attempts at healing [8]. Possibly because of its focus on symptom and treatment burden, rather than the more traditional curative models, palliative care is one area in which psychosocial factors are more likely to be considered. Therefore, wound care in the context of palliative care is also more likely to consider psychosocial factors. Indeed, they have been described by Emmons and Lachman [21▪] as ‘inherently connected’.

Having conducted the assessment, it is important that the management plan be designed to address all of the identified issues. However, in the case of psychosocial issues, this is often not the case, and there are many instances of authors highlighting the importance of psychosocial issues in chronic wound care, but then including only physical management in the subsequent care plan. Gethin [22] is one such example. She recognized and discussed the impact on QOL for patients with malodorous wounds. She then went on to discuss the physical management of malodour, but did not suggest any strategies for managing the patient's QOL issues. Presumably, the physical management of malodour might reduce the quality-of-life issues, but presuming on behalf of patients can lead to substandard care. It would be preferable to include strategies for managing the physical and psychosocial issues identified during assessment. In another case, it was interesting to note that, despite recognizing the importance of psychosocial issues, they were not included in any of the three mnemonics suggested by the authors for the management of wounds. Again, the focus was on the management of physical symptoms only. This phenomenon helps to explain the statistics presented earlier that, although mood disorders were identified in 50–75% of patients with chronic wounds, few were receiving treatment for them [11▪▪].

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Management

Despite the evidence of a link between psychosocial issues and wound healing and nonhealing, the focus on physical management of chronic wounds has resulted in limited literature to date on the strategies to manage psychosocial issues. However, there are some studies that have evaluated interventions to enhance wound healing by increasing positive affect. Broadbent et al.[15▪▪] reported a randomized controlled trial (RCT) in which the intervention group received standard care preoperatively and postoperatively plus a health psychologist consultation (45 min), including instruction in guided imagery and relaxation (deep breathing and progressive muscle relaxation) plus take-home CDs. They listened to one CD for 3 days before surgery (laparoscopic cholecystectomy) and a different recording for 7 days after surgery that focussed on body healing. The intervention group reported decreased stress and increased hydroxyproline deposition at 7-day follow-up. Hydroxyproline is an amino acid that gives stability to the triple helix structure of collagen, rendering it useful as an indicator of wounds in the proliferative stage of healing [15▪▪].

Vedhara et al. described ‘limited’ previous approaches to reducing the recurrence of chronic wounds because they failed to take account of the psychosocial factors that might be influencing the recurrence. On the basis of the principles of cognitive behavioural therapy (CBT), they developed and tested a two-phase psychosocial intervention to modify the risk of recurrence of DFU by assisting patients to change the way they think and behave. The first phase aimed to initiate change in the psychosocial risk factors already identified, while the second aimed to maintain those changes in the long term. Outcomes included increased social support, decreased depression, stronger beliefs regarding treatment control, greater understanding of their condition and increased self-care behaviours. Participants found the sessions enjoyable and helpful, particularly the opportunity to share stories with other patients with similar experiences. The benefits of sharing experiences and developing positive and lasting relationships have also been recognized by other authors [1▪▪,14▪,23▪].

Broadbent and Koschwanez [2▪▪] discussed evidence from two RCTs demonstrating that psychological interventions can enhance wound healing. In the first RCT, surgical patients (postradical prostatectomy) in the intervention group demonstrated lower presurgical mood disturbances, plus higher levels of natural killer cell cytotoxicity and circulating proinflammatory cytokines postsurgery. The second RCT was of a ‘leg club’ in which patients reported significant improvements in QOL, morale, pain, self-esteem and wound healing (less oedema, less venous eczema, more epithelial and granulation tissue and smaller mean ulcer area). Also evaluating the benefits of leg clubs was Shuter et al.[23▪] who discussed the clubs’ participatory action framework that enabled and empowered participants to improve their own social context through emphasis on social interaction and peer support. The report by attendees of greater morale and perceptions of social support is important because social isolation has not only been identified as a major effect of chronic wounds, but also as a contributor through resultant nonconcordance. An added benefit of the leg clubs is the opportunity for respite and social support for carers [23▪].

Although assessment and management must take account of the whole person, not just the wound, there is evidence that wound healing can improve QOL. Londahl et al.[14▪] found that hyperbaric oxygen improved diabetic ulcer healing, with a consequent improvement in HRQOL in eight domains of the SF-36: physical functioning; bodily pain; general health perception; vitality; social functioning and role limitations because of physical, emotional and mental health.

Other strategies for enhancing mood with a view to improved wound healing included yoga, mindfulness meditation, cardiovascular exercises, muscle relaxation, tai chi, cathartic writing, self-efficacy enhancement and pharmacological support for mood disorders [4▪,17▪▪,18▪▪]. Garcia-Morales et al.[6▪] also found that living with a healthy person was the most positive variable to improve the HRQOL of people with diabetic foot ulcers. Another important point raised by Pragnell and Neilson [1▪▪] is the wisdom of balancing expenditure and realistic healing times. If a wound dressing is likely to be effective but there are reservations about its usage because of expense, consideration should be given to the possible cost of the wound remaining nonhealing for many months, then eventually applying the more costly dressing as a last resort. Not only has the whole process been more financially unsuccessful, but also has inflicted needless suffering on the patient.

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CONCLUSION

There is ample evidence of a significant reciprocal link between psychological stress and wound healing (mainly acute), and also evidence of the importance of holism when managing patients’ health. Despite this evidence, this review has identified that the majority of literature on the topic of psychosocial issues and wound healing has focussed on acute wounds and typically omitted any recommendations for managing the identified psychosocial issues. There is a need for more research into the link between psychosocial issues and chronic wound healing and nonhealing. These findings can inform the development of treatment plans that address all of the health requirements of a patient with a chronic wound, rather than just concentrating on the physical management of a chronic wound.

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Acknowledgements

None.

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Conflicts of interest

There is no funding or conflict of interest to disclose.

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REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 124–126).

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REFERENCES

1▪▪. Pragnell J, Neilson J. The social and psychological impact of hard-to-heal wounds. Br J Nurs 2010; 19:1248–1252.

Although outside the review period, this article is considered important because it provides a rich illustration of one patient's experience of living with a chronic wound.

2▪▪. Broadbent E, Koschwanez HE. The psychology of wound healing. Curr Opin Psychiatry 2012; 25:135–140.

A review article, focussing on the link between psychological factors and biological mechanisms in wound healing. This study discusses the RCT evidence that psychological interventions can enhance wound healing.

3▪. Faria E, Blanes L, Hochman B, et al. Health-related quality of life, self-esteem, and functional status of patients with leg ulcers. Wounds 2011; 23:4–10.

This study found that the presence of venous ulcers adversely affected the quality of life and functional status of patients.

4▪. Finlayson K, Edwards H, Courtney M. Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study. J Adv Nurs 2011; 67:2180–2190.

This study found that psychosocial factors were significantly asociated with the risk of recurrence of venous leg ulcers.

5. Gaind S, Clarke A, Butler PEM. The role of disgust emotions in predicting self-management in wound care. J Wound Care 2011; 20:346–350.
6▪. Garcia-Morales E, Lazaro-Martinez JL, Martinez-Hernandez D, et al. Impact of diabetic foot related complications on the health related quality of life (HRQol) of patients: a regional study in Spain. Int J Low Extrem Wounds 2011; 10:6–11.

This study found that the presence of diabetic foot ulcers was so severe that it was rated by the patients as the most negative complication of diabetes, rated worse than a unilateral amputation of a lower limb.

7. Martin F, Duffy A. Assessing and managing venous leg ulcers in the community: a review. Wound Care 2011; 16:S6–S14.
8. Nenna M. Pressure ulcers at end of life. Home Healthcare Nurse 2011; 29:350–365.
9. Paul JC, Pieper B, Templin TN. Itch: association with chronic venous disease, pain, and quality of life. J Wound Ostomy Continence Nurs 2011; 38:46–54.
10▪▪. Upton D, Hender C. The cost of mood disorders in patients with chronic wounds. Wounds UK 2012; 8:107–109.

This study recognizes that understanding the causes of mood disorders in patients with chronic wounds and how to manage and prevent them is essential to encourage wound healing and avoid the substantial burden placed on individuals and society. The authors also discuss the importance of avoiding the ‘vicious circle’ of wound healing and mood disorders.

11▪▪. Upton D, Hender C, Solowiej K. Mood disorders in patients with acute and chronic wounds: a health professional perspective. J Wound Care 2012; 21:42–48.

This study found that 50–75% of patients with chronic wounds and 25% of patients with acute wounds were experiencing mood disorders related to their condition, but few were receiving treatment for their mood disorders.

12▪. Upton D, South F. The psychological consequences of wounds: a vicious circle that should not be overlooked. Wounds UK 2011; 7:136–138.

The authors discuss the growing evidence that the psychological impact of a chronic wound on a patient is clinically relevant.

13▪▪. Vedhara K, Beattie A, Metcalfe C, et al. Development and preliminary evaluation of a psychosocial intervention for modifying psychosocial risk factors associated with foot re-ulceration in diabetes. Behav Res Ther 2012; 50:323–332.

The authors suggest that previous approaches to ulcer prevention have been limited by their failure to take account of the psychosocial determinants of ulceration, so they developed and tested a psychosocial intervention that appeared to offer an acceptable and effective way of modifying the psychosocial risk factors associated with re-ulceration of DFU. The intervention was designed in line with the principles of CBT to assist patients to change the way they think and behave to bring about physiological and emotional changes.

14▪. Londahl M, Landin-Olsson M, Katzman P. Hyperbaric oxygen therapy improves health-related quality of life in patients with diabetes and chronic foot ulcer. Diabet Med 2011; 28:186–190.

Impacts of DFU are severe and include economic cost, reduced mobility, deficits in DLA, harmful influence on HR-QOL and negative impact on psychological status and social situation. The authors conducted a study that provided evidence that hyperbaric oxygen therapy can improve the health-related QOL in diabetic patients.

15▪▪. Broadbent E, Kahokehr A, Booth RJ, et al. A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial. Brain Behav Immun 2012; 26:212–217.

The authors present the results of a randomized controlled trial that showed improved acute wound healing in participants in the intervention group who received health psychologist consult (45 min), guided imagery and relaxation, plus take-home CDs for the periods before and after surgery.

16▪▪. Koschwanez HE, Broadbent E. The use of wound healing assessment methods in psychological studies: a review and recommendations. Br J Health Psychol 2011; 16:1–32.

A good review of the previous literature on the link between psychological factors and wound healing, even though much of that literature is focussed on acute wound healing which is likely to be different to chronic wound healing and nonhealing. The authors suggest biological mechanisms influencing healing and nonhealing.

17▪▪. Gouin J-P. Chronic stress, immune dysregulation, and health. Am J Lifestyle Med 2011; 5:476–485.

An investigation of the link between chronic psychological stress and immune dysregulation, including comparison with the effects of acute psychological stress which are typically less injurious to health. A good review of the previous studies on this topic.

18▪▪. Gouin J-P, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am 2011; 31:81–93.

Increasing and strong evidence that psychological stress and other behavioural factors can affect wound healing. A good review of the previous studies investigating this link, including some discussion of the biological mechanisms.

19▪. Lucas VS. Psychological stress and wound healing in humans: what we know. Wounds 2011; 23:76–83.

A good review of the previous studies investigating the link between psychological stress and wound healing in humans.

20. McKenzie H. Wound care is not holistic patient care. Home Healthc Nurse 2011; 29:259–260.
21▪. Emmons KR, Lachman VD. Palliative Wound Care. J Wound Ostomy Continence Nurs 2010; 37:639–644.

The authors provided a definition of palliative wound care as a ‘holistic integrated approach to care that addresses symptom management and psychosocial well being, is multidisciplinary, is driven by patient and family goals, and is integrated into wound healing principles and everyday practice’, with a focus on wound symptom and treatment burden.

22. Gethin G. Management of malodour in palliative wound care. Wound Care 2011; 16:S28–S36.
23▪. Shuter P, Finlayson K, Edwards H, et al. Leg clubs: beyond the ulcers. Wound Pract Res 2011; 19:16–20.
Keywords:

assessment; chronic wound; psychosocial

© 2013 Lippincott Williams & Wilkins, Inc.