The Pain and Stress of Wound Treatment in Patients With Burns

An International Burn Specialist Perspective

Dominic Upton, PhD, FBPsS; Jessica Morgan, BSc; Abbye Andrews, BSc, MBPsS; David B. Lumenta, MD; Michael Giretzlehner, PhD; Lars P. Kamolz, PhD, MSc


Wounds. 2013;25(8):199-204. 

In This Article

Abstract and Introduction


This study aimed to explore the views of burn specialists on the importance of reducing stress and pain during wound treatment.

Methods. Burns specialists were invited to complete an online survey, consisting of 10 questions about pain and stress in their patients.

Results. There were 141 respondents from 39 countries. Most were European (54.9%), and the majority were surgeons (71.8%). Pain-free and stress-free dressing changes were viewed as important overall ('very important:' 47.5% and 40.8%, respectively), although, in both cases, 11.3% did not view either to be important. Respondents identified 7 benefits of simple, pain-free dressing removal, although the focus was on clinical advantages rather than being patient-centered. Although most acknowledged that pain is linked with stress, disagreement levels ranged from 21.9% to 25.3%. Additionally, only 22.5% agreed that stress is related to wound healing.

Conclusion. In general, burn specialists recognized that pain can lead to stress and that it is important to reduce stress and pain at dressing changes. Most also acknowledged that stress can affect wound healing. However, these results suggest a need for research to further explore perceptions about pain and stress, and how these perceptions can impact wound management regimes.


Burn injuries are one of the most devastating forms of individual trauma. However, with advances in medical treatment techniques, the mortality rate for patients with burns has been reduced in recent years.[1] Due to such progress, a person with burns over 80% of his total body surface area (TBSA) now has a realistic chance of survival.[2] This reduction in patient mortality, though positive, has implications about the challenges these individuals will face in their lives in terms of long-term treatment, adjustment to daily life, and rehabilitation.[3] Consequently, burn wounds have being compared to chronic illness, with a high incidence of physical and psychological morbidity.[1,4]

Severe pain is one of the most significant components in the long-term suffering of burn patients,[5] with continuous background pain experienced alongside intense pain during wound treatment procedures. Often patients with burns must endure 1 or more painful procedures daily, for weeks or months,[6] comprising wound cleansing, debridement, dressing changes, surgical operations, and physical and occupational therapies.[7–9] The pain experienced during wound care procedures has often been reported to be excruciating.[10,11]

Much research has been conducted within the chronic wound population on the psychological effects of dressing-related pain, with stress being a common component.[12–14] Likewise, anxiety and depression are frequently reported to accompany the pain of burns, often having a bidirectional relationship.[15–16] Due to the emotional and physical trauma that patients with major burns experience, high levels of distress and anxiety are common.[17] Additionally, stress and anxiety are thought to be interlinked with pain, with anxiety increasing due to the anticipation of pain, and the experience of anxiety also intensifying the perception of pain.[18–19] This is cyclical in that the intense pain often leads to anxiety in anticipation of upcoming pain, such as that experienced with dressing change.[20] Due to the amplification of pain, by anxiety and stress levels, for patients with burns, it is important that treatment methods simultaneously target both the physical and psychological aspects of burn injuries.[1]

The consequences of pain, anxiety, and stress on wound healing provide further incentive to ensure treatment protocols incorporate techniques that aim to reduce these experiences for patients with burns as much as possible. It is known that pain can adversely affect the healing of a wound[15,21] and can also have a negative impact on quality of life.[22] A study by McGuire et al[23] found that in gastric bypass surgery patients, reports of postsurgical, high-intensity pain were associated with longer healing times. Similarly, Woo and Sibbald[24] found that the mean pain scores over a 4-week period for patients with leg or foot ulcers was significantly less (P < 0.041) for those who achieved wound closure (mean pain score 1.67), than for those who did not (mean pain score 3.21).

In a way similar to pain, increased stress levels can also delay the healing process.[25,26] Broadbent et al[27] explored the effects of stress levels on wound healing in patients who underwent a laparoscopic cholecystectomy. It was found that those who received a psychological intervention aimed at reducing stress, in addition to standard care, showed lower stress levels and enhanced wound healing postsurgery compared to those who received standard care alone. Similar findings have been reported in regard to individuals with burns. For example, Wisely et al[28] investigated the effect of preexisting psychiatric disorders and psychological reactions to stress on the recovery of burn survivors. It was reported that heightened psychological distress alone, without the presence of a psychiatric disorder, had a significant delaying effect on the rate of recovery of burn wounds. This finding highlights the importance of identifying and working with difficulties, such as stress and anxiety, in light of the psychosocial and physical impact they may have on recovery.

The effect that both pain and stress have on wound healing makes it important for professionals to reduce the pain and stress their patients experience during treatment, especially for those whose burns require regular wound care procedures.

Despite the importance of pain and anxiety management in burn treatment regimes, Robert et al[29] found it can be omitted during clinical assessments. The authors surveyed nursing directors at 64 burns centers. Of the burn teams, 19% (12 teams) did not assess anxiety at all during the treatment of burn wounds, neither formally nor informally, despite its importance in the pain experience of patients, and the subsequent healing of their wound.

However, it must be noted that many medical professionals are aware of the psychological impacts of wounds upon patients. For example, Upton et al[30] surveyed health care professionals in relation to patients with acute and chronic wounds. The majority of professionals believed that more than half of their patients suffered from mood problems related to their condition. These problems were most likely to include anxiety and feelings of helplessness, with chronic pain and discomfort of the wound acting as potential contributory factors. Further research is needed to build upon the knowledge of how important burn specialists perceive pain and stress to be, and how highly they rate the need for pain- and stress-free management regimes for burn recovery.

The present study aimed to explore clinicians' views about pain and stress in their patients with burns. In particular, this research aimed to investigate how clinicians perceive the relationship between pain and stress, and how important they consider reducing pain and stress during treatment. Additionally, this research aimed to look at beliefs about how stress affects wound healing.