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Original Article

The Journey to Chronic


Pain: A Grounded Theory
of Older Adults
Experiences of Pain
Associated with
Leg Ulceration
Tarnia Taverner, PhD, MSc, RGN,*
S. Jos
e Closs, PhD, MPhil, BSc, RGN,
and Michelle Briggs, PhD, BSc, RGN

---

From the *University of British


Columbia, Vancouver, British
Columbia, Canada; University of
Leeds, Leeds, United Kingdom.
Address correspondence to Tarnia
Taverner, PhD, MSc, RGN, University
of British Columbia, T201-2211
Wesbrook Mall, Vancouver, BC,
Canada V6T 2B5. E-mail: tarnia.
taverner@nursing.ubc.ca
Received February 9, 2011;
Revised August 8, 2012;
Accepted August 10, 2012.
Supported by Pfizer
Pharmaceuticals.
1524-9042/$36.00
2014 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2012.08.002

ABSTRACT:

This study aimed to develop a grounded theory to describe and explain


the experience of pain and its impact, as reported by the individuals
who had pain associated with chronic leg ulceration. The Strauss and
Corbin grounded theory approach was used. In-depth interviews were
undertaken with 11 people aged $65 years from Leeds in the north of
England. All participants were cared for by home care nurses and had
painful leg ulceration. The emergent grounded theory centered on
a core category of The journey to chronic pain. The theory suggested
a trajectory consisting of three phases that the patient experiences,
where the end result is a chronic pain syndrome. In phase 1, leg ulcer
pain has predominantly acute nociceptive properties, and if this is not
managed effectively, or ulcers do not heal, persistent pain may develop with both nociceptive and neuropathic properties (i.e., phase 2).
If phase 2 pain is not managed effectively, patients may then develop
refractory long-term pain (phase 3). Those who progress to phase 3
tend to experience negative consequences such as insomnia, depression, and suicidal ideation. Only when health care professionals understand and acknowledge the persistent and long-term nature of the
pain in this patient group can the pain be managed effectively.
2014 by the American Society for Pain Management Nursing
Pain as a symptom associated with chronic leg ulceration should be expected,
because noxious stimuli are a consequence of tissue damage. Acute nociceptive
pain is usually self-limiting; it is a short-term pain of <12 weeks duration (British
Pain Society [BPS], 2008). Acute pain has an obvious cause, and its purpose is to
warn of injury and/or damage (Nagy & Rice, 2003). Chronic pain, in contrast, is
long-term pain lasting >12 weeks, or for longer than the time in which healing
would have normally occurred (BPS, 2008). Chronic pain is defined by the
Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 186-198

The Journey to Chronic Pain: A Grounded Theory

International Association for the Study of Pain (IASP,


2007) as a multidimensional phenomenon characterized by unpleasant sensory and emotional experiences.
For some people, neuropathic pain is associated with
chronic pain. Neuropathic pain is initiated or caused
by a primary lesion or dysfunction in the peripheral or
central nervous system. Furthermore, wounds become
chronic because they do not follow the normal wound
healing trajectory associated with acute wounds.
Chronic wounds remain in the inflammatory phase
for too long (Snyder, 2005). The inflammation stage is
the second stage of wound healing and presents with
erythema, swelling, warmth, and often pain. In studies
investigating the prevalence of pain in this patient
population, at least three-fourths of participants reported moderate to severe pain (Briggs, Bennett,
Closs, & Cocks, 2007; Chase, Whittemore, Crosby, &
Freney, 2000; Hareendran, Bradbury, Budd, Geroulakos,
Kenkre, & Symonds, 2005; Nemeth, Harrison, &
Graham, 2004; Park, Ferreira, & Santos, 2008; Phillips,
Stanton, Provan, & Lew 1994; Price et al., 2008;
Wissing & Unosson, 2002). Empirical evidence has
shown that patients with leg ulceration are very likely
to have pain (Park, Ferreira, & Santos 2008; Briggs
et al., 2007). These papers described the intensity of
the pain experienced and provided some information
about the etiology of the pain. Briggs et al. (2007) investigated the incidence of neuropathic pain in patients with leg ulceration and found that 45.3% of the
patients (n 43) had signs and symptoms of neuropathic pain. Neuropathic pain can be associated with
acute nociceptive pain. However, neuropathic pain is
likely to last longer that nociceptive pain because it
is more difficult to treat and is associated with conditions that have a longer time scale and that are chronic
(Attal, Cruccu, Haanpaa, Hansson, Jensen, & Nurmikko,
2006; Dworkin, Backonja, & Rowbotham, 2003;
Finnerup, Otto, & McQuay, 2005). Park, Ferreira, and
Santos (2008) in their cross-sectional study of 40 patients with venous leg ulcers, did not assess patients
for neuropathic pain, but they did assess the pain characteristics with the Short-Form McGill Pain Questionnaire. Sensory words chosen by the patients to
describe their pain were throbbing (70%; n 28),
pricking (75%; n 30), sharp (75%; n 30), and burning (65%; n 26). Clinically, neuropathic pain is associated with sensory symptoms such as burning and
pricking (Bennett, 2001; Bouhassira et al., 2005). Reports of pain from qualitative research are also available, although the majority of these studies did not
specifically investigate pain (Chase, Whittemore,
Crosby, & Freney, 2000; Douglas 2001; Ebbeskog &
Emami, 2005; Flaherty, 2005; Husband, 2001a,
2001b; Hopkins, 2004; Walshe, 1995). Rather, they

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explored what it was like for people to live with leg ulceration. Although they discussed the presence of
pain, the etiology of that pain and its management
were not fully explored. Pain was identified as one
theme which was then discussed within the results
of the experience of living with leg ulceration.
Krasners (1998) was the only qualitative study that
specifically investigated the pain experience. Krasner
used phenomenologic methods, and therefore described the lived experience, but did not develop
theory to explain what underpinned participants
experience.
Husband (2001a, 2001b) and Douglas (2001) undertook grounded theory studies investigating patients
with venous leg ulceration. Husbands study (2001a,
2001b) provided interesting insights: Nurses tended
to set priorities related to the leg ulcer, whereas the
patients wanted help in pain management and in normalizing their lives. Husband suggested that care only
focused on the acute phase of an underlying chronic
condition. A systematic review of qualitative studies
confirmed this view that leg ulceration should be
viewed as a chronic debilitating condition and that
patients would be best served if the clinical focus of
care could be shifted more toward symptom management (Briggs & Flemming, 2007).
Husband, however, neither provided in-depth information about the pain experience nor discussed
the impact or subsequent effect of the pain on the participants lives. She simply identified that patients had
pain that was not managed. A major category identified
by Douglas (2001) was the physical experience of ulcers, and pain was a subcategory within that. However,
Douglas discussion focused on the impact of pain on
patients compliance with treatment. The focus of
the work remained on the healing aspect, and it was
suggested that by managing pain, patients compliance
would increase. Flahertys (2005) study was of particular interest because patients with healed venous leg ulcers were interviewed (n 11). There was some
description that suggested that these patients continued to suffer with pain despite their ulcers having
healed. Furthermore, the pain was described in
a way that suggested a neuropathic element. However,
Flaherty did not discuss neuropathic pain but simply
described the pain as something that patients with
healed venous ulcers reported.
Overall, the majority of the researchers did not
make the link between the pain experience these
patients described and the pain experience described by others with chronic pain. Jones, Barr,
Robinson, and Carlisle (2006) discussed their findings briefly within the context of the pain literature
but came to the conclusion that patients with leg

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Taverner, Closs, and Briggs

ulceration were at risk of depression associated with


pain and odor. They did not develop their analysis
further to consider the chronic pain condition. The
qualitative literature in particular revealed that patients
had pain, but the nature of the pain experience was
not developed in greater depth. There was limited discussion of the pain experience within the context of
the wider pain literature. It was apparent from the literature that patients with pain associated with leg ulceration were at risk of developing a chronic pain
condition. The topic of pain associated with chronic
leg ulceration needs to be explored with more emphasis on the etiology of the pain, its management, and related consequences for the patient experiencing the
pain.
The literature did not describe the effect of pain
on patients with leg ulceration, and it did not describe
the etiology of the pain from the patient perspective.
Although there was evidence that patients with leg ulceration may have nociceptive as well as neuropathic
pain and that this pain may not be well managed, there
was no available evidence exploring the pain experience in depth. However, we did not want to develop
theory that was remote from that already described,
but wanted to focus on verification of existing theory
and hypothesis testing (Strauss & Corbin, 1998) within
the context of the available literature.
The present study aimed to develop a grounded
theory to describe and explain the experience of
pain and its impact, as reported by the individuals
who had pain associated with chronic leg ulceration.

METHOD
The Strauss and Corbin (1990) grounded theory
method was used because this allowed for theory verification and development within the context of the
available literature. It also allowed a researcher to use
previous knowledge and experience to provide insight
regarding patients experiences, acting as a hybrid researcher as described by Jootun and McGhee (2009).
A hybrid researcher is someone who researches in familiar territory and who may have inherent biases
and assumptions. The researchers knowledge regarding pain allowed for greater understanding of the
pain experience described by the participants of the
study. The underlying assumption of grounded theory
is that people make sense and order of their social
world even though, to the outsider, their world may appear irrational. Individuals sharing common circumstances (e.g., people with chronic pain) experience
common perceptions, thoughts, and behaviors, which
are the essence of grounded theory (McCann & Clark,
2003a).

Ethics approval was obtained from the National


Health Research and Ethics Committee in accordance
with the policies and participating organizations.
Signed consents were obtained from participants at
the time of interview.
Sample
Participants were invited to participate by their home
care nurses and were provided with study information
leaflets. At a subsequent meeting with their home care
nurse, if they wished to volunteer for the study the
home care nurse took personal details that were then
forwarded to the researcher. The researcher then
made contact with the participant to arrange to obtain
signed informed consent and for a time and venue to
be arranged for a one-to-one interview.
The sample for this study consisted of 11 adults
who had an active leg ulcer (below the knee and above
the malleolus). Twelve participants were recruited but
one was withdrawn because she did not have pain associated with her leg ulcer. To allow for understanding
of the phenomenon of older adults living with pain associated with chronic leg ulceration, participants were
selected based on the following criteria: 1) aged $65
years; 2) undergoing treatment for a leg ulcer in the
community; 3) had a diagnosed chronic leg ulcer below the knee and above, on, or around the malleolus;
4) had pain associated with their leg ulcer; 5) had the
cognitive ability and English language ability to undertake the interview. The selected sample was guided
during the constant comparative process, the emerging categories, and the saturation of the data. There
are no tests to determine sample size needed, but
rather several factors determine sample size. These factors include the scope of the research question, the researchers knowledge and ability in the topic of the
research, and the ability of the interviewees to express
their experiences to form the data (Corbin & Strauss,
2008). The present study had a narrow research focus
and the researcher had considerable experience and
knowledge of the topic under investigation. Therefore
it was possible to obtain sufficient data with fewer participants. Once the codes started to represent a pattern
that demonstrated theory, saturation was achieved
(Munhall, 2006).
Data Collection and Analysis
The participants were recruited from a health authority
in Leeds, in the north of England. The researcher carried out all of the interviews; which were audiotaped
with the participants permission. The interviews
were semistructured; some control of topics was assumed, using questions as prompts to encourage the
participants to discuss issues that were pertinent

The Journey to Chronic Pain: A Grounded Theory

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the grounded theory methods, and use of the theoretical memos as an audit trail. While carrying out the
data collection, analysis, and development of theory,
a reflective approach was undertaken to enhance credibility and to provide assurance that the theory development was an accurate representation of what the
participants described. A further strategy used to ensure credibility was the use of an independent coder.
Another experienced researcher (M.B.) read the interview transcripts and independently identified categories. The coding was then compared with the first
authors (T.T.) work to increase the credibility of the interpretation of the results (Appleton, 1995).

(Bluff, 2005). During the initial phase of the data collection, the researchers knowledge and experience of the
topic facilitated the process (Strauss, 1987). The focus
of the prompts/questions changed throughout the
grounded theory process in line with the constant comparative method. With this approach, data collection,
theoretical sampling, analysis, and review of relevant
literature all occurred concurrently. Sampling and further data collection were based on the emerging theory
(Strauss & Corbin, 1998). The researcher used an
inductive-deductive approach (going back and forth between the data and the emerging concepts and theory)
to generate and extend the theory. The literature that
was relevant to the emerging theory was accessed
and read with the aim of comparing the literature
with emerging theory, in the same way that data were
compared to the emerging theory. The process was
a circular one and involved going back to the data
and returning to the participants (Marcellus, 2005).
The data were systematically collected, organized,
and examined after each interview. Subsequent interviews were coded with the emerging theory in mind.
Along with memo writing, which aided the development of the codes and emerging theory, the data
were returned to, and further participants were interviewed, to verify the categories developed. The
grounded theory model offers a framework for axial
coding, which is the process of relating codes to each
other, through a combination of inductive and deductive thinking. To assist with coding and categorizing
the data, the QSR NVivo 9 computer program was used.

Description of Codes
In the stage of initial coding, 45 codes were identified,
during the data analysis; categories were identified and
developed in terms of their properties and dimensions.
During the process, seven central categories were
identified (Table 2);
Selective coding identified three central categories: the chronic pain condition, trying to manage
the pain, and conflicting focus. The core category
the journey to chronic pain became the core category theme that was grounded in the data.

Credibility
Strategies used to ensure trustworthiness and credibility of the data analysis included reflexivity, in line with

The Chronic Pain Condition


The participants gave descriptions of their pain before
and when the ulcer developed. Some reported that it

RESULTS
Eleven participants were recruited over a study period
of 6 months; data collection started in February 2005
and ended in September 2005 (Table 1).

TABLE 1.
Demographics of Study Participants
Participant Number and Gender
1
2
3
4
5
6
7
8
9
10
11
12

Female
Male
Female
Female
Female
Female
Female*
Male
Female
Female
Female
Female

Ethnicity

Age, y

Leg Ulcer Etiology

Chronicity

White
White
White
White
White
White
White
White
White
White
White
White

83
90
84
100
79
81
77
72
68
77
97
69

Venous
Venous
Venous
Venous
Venous
Venous
Venous
Arterial
Mixed venous/arterial
Arterial
Venous
Mixed venous/arterial

20 y
18 mo
10 y
1y
2y
8 mo
2y
2y
3y
20 y
7 mo
15 y

*Patient withdrawn from study, because she did not have pain related to their leg ulcer.

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TABLE 2.
Diagram of Coding
Initial Coding

Axial Coding (n 7)
1. Pain experienced

Elevating legs/resting
Pain impact on mobility
Loss of independence
due to pain
Dependency on health
care professionals

Distraction
Analgesics:
Chronicity
 acetaminophen Complementary/
Cycle of leg ulcer
alternative medicine
 codeine
Neuropathic pain
Positioning
 morphine
Insomnia
Adverse events:
Depression
 constipation
Suicidal ideation
 overdose
 polypharmacy
Advice regarding
analgesics by
health care
professionals
Effectiveness of
pharmacologic
management
Preemptive
analgesics
Pharmacologic
management of
neuropathic pain

Help-seeking behavior Nurse response to


report of pain
Exercise
Pain as a good sign
Trying to understand
Pain management
the pain
for procedural pain
Desire for amputation
Family practioner
comments
Pharmacologic pain
management
advice
Professional tennis

2. Loss Of freedom

3. Chronic pain
sequelae

6. Patients attitudes
and behaviors

Selective Coding (n 3)
1. The chronic pain condition
Core Category
The journey to chronic pain

4. Pharmacologic
management

5. Nonpharmacologic
management

2. Trying to manage the pain

3. Conflicting focus

7. Health care
professionals
attitudes and
management
of pain

Taverner, Closs, and Briggs

Initial pain sensations:


 Itch
 Pain severity
Constant pain
Changes in pain
Correlation between
ulcer size and pain
intensity
Nocturnal pain
Compression
bandaging
Procedural pain

The Journey to Chronic Pain: A Grounded Theory

was the pain that led them to seek medical help. The
severity of the pain was reported as different and
some patients reported itching sensations. During the
data collection and analysis it became clear that patients
had different experiences related to their pain. There
was a difference in the severity of the pain reported at
the point of the development of the ulcer. There was
no obvious reason for this, and it was not possible to
state the expected pain intensity at time of development
of the leg ulcer. Participant 4 explained, it was just irritating. But others described severe pain, yes at the
beginning absolutely terrible (participant 11). Pain initially is nociceptive and its purpose is to alert the
patients to their wound, which patients described:
Once it started, it hurt. It hurt, then I thought, you
know, I went to the doctors.
Some participants reported that the pain was not
that bad initially, it was only once treatment was commenced that the ulcer became painful. Participant 11
clearly described this occurrence: It was treated
then, but oh the pain . it was really, it was terrific. I
can not say it was ordinary, it was really, really bad.
All except one of the participants reported that the
treatments used to heal the leg ulcer exacerbated their
pain. This was particularly apparent with regard to
compression therapy. Participants often described
that the bandaging was the worst aspect associated
with having a leg ulcer, because it exacerbated their
pain. Participant 12 stated, They put on layer bandaging, I stuck it out and then last time Id had them on
a week it were absolute agony.
This suggested that despite the exacerbation in
pain caused by the bandaging, they tried to tolerate
the pain to enable the management. Some participants
described having intense pain regardless of the size of
the ulcer. The participants did not report a reduction
of pain with healing; instead they described constant
pain with exacerbations of pain for no obvious reason.
An example of this occurrence was given by participant 10: Ive got two leg ulcers, one either side and
one is a very small one and thats a painful sod but
the other ones not bad at all.
The participants predominantly reported that
they had constant pain, which may have changed in etiology but not necessarily in severity. They described
the pain as being present all the time. Some described
the pain as coming and going but reported experiencing some sort of pain all the time.
The participants often described their pain with the
use of neuropathic pain descriptors, and some talked
about their nerve pain. The participants also described
allodynia and hyperalgesia. One (participant 12) discussed the pain caused by wearing footwear, which
gave a clear description of allodynia: I could not stand

191

nothing right now if I had any shoes on that . came anywhere near it. Oh you can feel it, that one, just touching it
underneath it, its pain that makes you scream. Another
(participant 9) gave a description that suggested hyperalgesia: Um, well down here its different; its absolutely
murder just to touch it with the gauze.
The neuropathic pain descriptors used included tingling and firing pains, burning pain, shooting pain, jumping pain, red hot pain, pricking pain, and nerve pains. An
example of this was provided by participant 5: Its the
tingling and firing pain that gets on me nerves.
The participants reported changes in pain, and
these changes were described having an obvious cause,
such as procedure-related pain, or were changes that
participants were unable to describe or determine the
cause of. Participants reported pain that would change
for no obvious reason; they described pains as shooting,
sudden, and short sharp bursts. For some participants,
this caused them confusion, as participant 8 described:
Ive tried to get some reason, I can not crack it, it can be
any time any place. There was a wide variation on pain
experienced during dressing changes. Some participants reported a sense of relief from the pain during
dressing changes, and others reported an exacerbation.
One particular description given by participant 2 was
striking and portrayed a rather harrowing image: Well
imagine like you are having the skin peeled off your leg.
Participants reported an exacerbation in pain on
mobilizing, which would restrict their level of activity.
The loss of mobility was also described as affecting individuals ability to carry out simple day-to-day tasks,
such as making a cup of tea or going to the toilet. Participant 5 reported that the discomfort prevented her
from undertaking simple tasks which compromised
the quality of independence: Its uncomfortable for
walking; it makes a walk to the toilet or going to the
kitchen to make myself a cup of tea difficult.
Others also described losing independence and
losing the ability to undertake day-to-day tasks, such
as housework, due to the pain. Participants dealt
with this by employing help or moving to a residential
care facility. Participant 4: Well I dont do anything really here, I dont do any house work or anything; I had
to come here [residential care] because I was not able
to do what I wanted to do.
Participants described entering a cycle of care that
focused on healing. One participant described being
dependent on their nurse so much that going on holiday was not possible, even though the nurses had tried
to solve this problem by offering to arrange nursing
care at the holiday destination.
Many of the participants reported having their leg
ulcers for many months, sometimes years, with the associated pain being present alongside the presence of

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Taverner, Closs, and Briggs

the chronic leg ulcer. The pain experienced and reported as such by this group has obvious similarities
to other chronic pain conditions along with associated
outcomes. The participants often reported sequelae associated with chronic pain such as insomnia, suicidal
ideation, depression, and isolation. These descriptions
were common, and all of the participants described
problems with sleeping because of the associated
pain from their leg ulcers. Participant 6 reported,
Its awful unrelenting, I get up and sit here rather
than lie in bed. The picture that the patient data
gave was one of patients desperately trying to sleep
with little or no success, and the participants descriptions of their pain and its impact on their quality of life
included depression as well as suicidal ideation. This
depression appeared to exacerbate the participants
sense of isolation. Participant 12 notably described
the pain as causing suicidal ideation: At the end, the
pain I had then, you see, when it were at its worse I
was quite willing to die.

The participants described a wide variation in


their pain experience. However, there were themes
that were commonly seen within the data: that the
pain described was chronic and that it was often worse
at night, causing insomnia. Neuropathic pain symptoms were apparent as well as sequelae such as insomnia, depression, and suicidal ideation. It is postulated
that if patients had their initial nociceptive pain managed, they may not have gone on to develop a chronic
pain syndrome. Figure 1 illustrates this conjecture.
Trying to Manage the Pain
Participants described using simple analgesics to manage their pain with little success. They were likely to
commence with acetaminophen and would then take
codeine.
There was no report of any pharmacologic management for neuropathic pain. Participants reported that
they found their analgesics to be inadequate but also reported not taking anything other than acetaminophen,

FIGURE 1. - A theoretical model depicting the journey from development of leg ulceration to development of a chronic pain
condition in older adults.

The Journey to Chronic Pain: A Grounded Theory

because they were concerned with constipation. Participant 1 reported that the constipation was worse than
the pain so would not take codeine. Other participants
were wary of taking too many medications. For example,
participant 8 stated, I have one or two pain killers. Im
a bit worried about, you know, rattling round like a pill
box. Polypharmacy was also expressed as a concern
and participants explained they didnt like taking lots
of medications. The participants reported various types
of advice given to them by their nurse or family practitioner (FP). It appeared from the patients reports that
the nurses felt at a loss as what to do about the pain
and that the FPs were reluctant to give stronger analgesics. Participant 4 described asking for something stronger for the pain but the request was refused by the FP:
Ive asked for stronger ones each time, the doctor said
that I can give them to you but I dont want to.
Some participants described using distraction or
positioning as a nonpharmacologic technique to manage the pain. There was also some report of complementary/alternative medicine use. Participant 12, in
an attempt to eliminate the pain, tried to freeze the
area with ice: I did try once putting ice on it, I tell
you what, it did hurt. I should not have done it, but
you know its just that I thought if I freeze it, it will go.
Conflicting Focus
Participants described accessing health care because of
the pain, but the focus of their care remained on the
healing and the pain was not addressed. Participant 1
went to the FP because of the pain but did not have
the pain managed: I know the lady doctor when it first
started, I used to complain about the pain, they never
suggested pain killers, no one ever, never took pain
killers, no one said I should.
The description of the pain and the extent of the
pain by the participants suggested a sense of confusion
regarding the severity of the pain and the ulcer. They
would try to downplay their suffering. Participants appeared to view leg ulceration as not a serious complaint, and because of this they expressed confusion
with the extent and impact of their pain. Participant
2 felt that she exaggerated her leg ulcer pain: I feel I
exaggerate the pain, it might be to someone just a little
discomfort, but to me its pain like burning.
Some participants also expressed a desire for leg
amputation and would rather lose their leg than continue with the suffering caused by their pain. Participant 12 described that when the pain got that bad he
would just want the leg taken off: You get so all you
want to do is take it off, you just wish they would
take the leg off.
Participants reported that the nurses did not appear to know what to do about the pain. Participant

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9 explained when asked by the interviewer, Do you


tell the nurses that it is very painful?, Um yes, but
they say they can not do anything about it.
When the patients complained that the bandaging
hurt, the nurses did not address the pain. The participants reports gave a sense of the nurses dismissing
the pain report. For example participant 1 reported,
The nurse said we blame everything on the bandage.
Others reported that their request to be seen by their
FP because of the pain was refused, and it appeared
from the participant reports that the FPs also were dismissing the patients pain reports. There also seemed
to be some suggestion that the nurses viewed the
pain as a good sign. Some participants were told by
their nurse that pain was a good sign; the participants
reported that the nurses told them if they had pain it
meant the leg was working.
Others reported that they were given antibiotics
when they complained of pain and were told that there
was nothing that could be done about the pain. Participants reported accessing health care because of the
pain, then described entering a care pathway that
was entirely focused on the healing of the leg ulcer,
which they described as exacerbating their pain.

DISCUSSION
The pain described by the participants in this study and
the effects the pain had on their lives suggest a picture
of chronic pain with several associated negative sequelae. Figure 1 is presented as an emergent theory
derived from these data as well as verification and development within the context of the available literature to
explain why the participants had developed a chronic
pain condition. The consequences for patients who
do not have their pain effectively managed can be profound. Chronic pain, insomnia, depression, and suicidal
ideation are inextricably linked. The evidence in the literature confirms that patients with chronic pain are at
risk of comorbidities, including insomnia, depression,
and suicidal ideation (Banks & Kerns, 1996; Breslau,
1992; Chaturvedi, 1989; Gallagher & Verma, 1999;
Hitchcock, Ferrell, & McCaffery, 1994; Kerns, Turk,
& Rudy, 1985; Latham & Davis, 1994; Lindsay &
Wyckoff, 1981; Magni, Caldieron, Rigatti-Luchinin &
Merskey, 1990; Ohayon, 2004; Ratcliffe, Enns, Belik,
& Sareen, 2008; Roy, Thomas, & Matas, 1984; Stenager,
Stenager, & Jensen, 1994; Turner & Romano, 1984;
Venkoba, 1990).
We provide a theoretical model to suggest that the
participants, on initial development of leg ulceration,
entered the leg ulcer management trajectory with
acute pain (phase 1). There was a disparity between
the patients about the severity of pain at the onset of

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Taverner, Closs, and Briggs

leg ulceration. Differing severities of pain experience is


to be expected. Pain is a personal experience that results from both the invasiveness of the painful stimulus
and how that stimulus is modulated by factors both external and internal to the individual (Stevens, WattWatson, & Gibbins, 2003). Furthermore, evidence
has determined that neither patient characteristics
nor leg ulcer characteristics such as ulcer type, size,
or duration can be used to determine pain intensity
or etiology (Briggs et al., 2007). Acute pain from leg ulceration is either associated with stimuli from dressing
changes or constant pain associated with inflammation. Acute nociceptive pain has a particular function:
It serves to aid tissue repair (Johnson, 2006). The term
pain with purpose provides a good description of
acute pain. Acute pain has a cause that patients and clinicians can diagnose. It is the bodys normal mechanism that manifests as pain (Nagy & Rice, 2003), and
in the case of leg ulceration the initial pain acts to alert
individuals to their leg ulcers. Recently, the literature
has demonstrated that patients may develop neuropathic pain symptoms within the first few days following trauma or injury (Searle, Matthew, Simpson, Milton,
& Bennett, 2009; Shipton, 2008), so it may be that on
initial development of a leg ulcer patients may also
experience neuropathic symptoms within the first
few days after injury or trauma. Therefore, for some
patients they begin the journey to chronic pain at
phase 2 because of the neuropathic pain component.
Chronic pain is continuous long-term pain of >12
weeks or after the time that healing should have occurred (BPS, 2008). Patients with pain associated
with leg ulceration are at risk of developing chronic
pain with neuropathic pain because of the inflammatory processes and because of the length of time the ulcer can take to heal (Laible, Mayer, & Evers, 2002).
Central sensitization may be triggered by primary nociceptive stimulation, on-going peripheral ectopic activity, or both (Treede, Handwerker, Baumgartner, Meyer,
& Magerl, 2004). If such a state persists, patients are at
risk of developing neuropathic pain. Furthermore,
older people are at greater risk of extended hyperalgesia, which may put them at greater risk of neuropathic
changes (Zheng, Gibson, Khalil, Helme, & McMeeken,
2000). It could be postulated with this theoretical
model that if the participants of this study had received
adequate pain management and assessment in phase 1,
central sensitization may have been prevented and the
participants may have avoided developing chronic
neuropathic pain (Shipton & Tait, 2005). This would
require further research and testing of the theory.
Those participants who described being in phase 3
described not having their pain acknowledged or managed appropriately. It is possible that the participants

were at greater risk of entering into phase 2 and 3 because they were older: Older people are less likely to
heal and are at greater risk of ulcer recurrence (Briggs
& Closs 2003; Graham, Harrison, Nelson, Lorimer, &
Fisher, 2003; Phillips, 1999). While the participants
were in phase 2 of the pain journey, their pain may
have been predominantly nociceptive but may also
have had a neuropathic element. They may not have
responded to acute pain management and may not necessarily have experienced a reduction in pain with
healing, in part because of the developing neuropathic
pain component. Reduction of acute pain and prevention of neuropathic pain are linked, in that any treatment reducing the intensity or the duration of the
acute pain has the potential to prevent or reduce the severity of neuropathic pain by preventing central sensitization (Wu, Marsh, & Dworking, 2000). The patients
pain was exacerbated because of the neuropathic component and associated leg ulcer treatments. Various
studies have provided evidence that in some cases, compression bandaging is so painful that patients are unable
to tolerate it (Briggs & Closs, 2006; Ebbeskog & Emami,
2005; Heinen et al., 2007; Mudge, Holloway, Simmonds,
& Price, 2006). Most of the participants in the present
study reported that compression exacerbated their
pain. Nonetheless, the nurses appeared to persevere
with this technique, likely because they were adhering
to best evidence to heal ulcers and current clinical
guidelines. This was understandable, because compression therapy is the mainstay of treatment and prevention of ulcers with venous etiology (OMeara, Cullum,
& Nelson, 2009; Royal College of Nursing, 2006). The
pain of compression therapy was to be expected if
these patients were also reporting neuropathic pain.
There were many descriptors given that suggested neuropathic pain. The pain associated with neuropathic
mechanisms is often described as a continuous burning
pain, or spontaneous lancinating or electric pain
(Bennett, 2006; Rasmussen, Sindrup, & Prasad, 2004).
Participants in the present study did not use the word
neuropathic, but they certainly used pain descriptors
suggesting that they may have had neuropathic symptoms. In Briggs et al.s (2007) study investigating pain
mechanism and intensity, it was found that 45.3% of
the participants had signs of neuropathic pain. It has
been shown that once patients have developed neuropathic pain, it is more difficult to manage (Bonezzi &
Demartini, 1999). None of the participants in the present study reported that they had been diagnosed as having neuropathic pain, and they were not receiving
treatments, such as trycyclic antidepressants or anticonvulsants, for neuropathic pain. Participants described confusion about the extent of their pain. This
was to be expected, considering that they did not

The Journey to Chronic Pain: A Grounded Theory

appear to have an understanding of the etiology of their


pain.
The participants demonstrated poor healing outcomes and reported having had their leg ulcers for
months and sometimes years. Despite this, they described a focus of care that remained on healing rather
than symptom management. The patients entered into
phase 3, where they had chronic pain with its associated outcomes. The participants reported that the
nurses continued to focus on the healing despite poor
healing outcomes; this was in conflict with the participants focus, which was on their desire for pain management. There was also some suggestion that the nurses
viewed the pain as a good sign. There is no apparent explanation for that, and it has not been discussed in the
available literature. It may be related to the loss of sensation that is apparent for some patients with diabetic foot
ulceration. For those patients, a loss of sensation has
been determined to be a risk factor associated with further damage to the foot (Walker, 2005). Therefore, the
nurses may view patients sensation and their ability
to feel pain positively.
No phase was exclusive; rather, phases 1, 2, and 3
describe the participants journey from the development of acute pain associated with leg ulceration to
the development of a chronic pain condition. Any
patient that has a chronic pain condition would have
had to go through specific physiologic pain processes
that would involve inflammatory responses and the development of neuropathic pain (McDermott, Toelle,
Rowbotham, Schafer, & Dukes, 2006; Treede et al.,
2004). Therefore, although the participants of this study
described being in phase 3, they would have had to pass
through phases 1 and 2 before entering phase 3.

STUDY LIMITATIONS
There are factors that may affect the credibility and reliability of this study. The home care nurses were responsible for putting participants forward and thus
served as gate keepers to the study and may have exercised some control on who was put forward. The research team was dependent on the nurses for sample
recruitment, and it is possible the breadth of data
may have been limited (Bluff, 2005). It is not possible
to state that all of the patients who would have been
potentially suitable for this study were approached
and invited to participate. One could suggest that it
would have been impossible for the home care nurses
not to have influenced the selection of participants.
The majority of participants were female with venous leg ulceration, and although this reflects the
higher prevalence of leg ulceration among women
and the higher prevalence of venous etiology, the

195

theory developed here may not be a true representation of mens experiences or the experience associated
with arterial etiology. However, data from the male participants and data from participants with arterial or
mixed etiology demonstrated a similar experience to
that described by the majority. While this may weaken
the study findings, it was the pain experience and its
outcomes, regardless of etiology, that was the focus.
All of the participants were white; this is probably
because the majority of the population in Leeds is
white British (82.5%) (Office of National Statistics,
2010), though there is a significant immigrant population in Leeds; inclusion criteria dictated that all of the
participants were required to undertake an interview
in English. Clearly, this study does not represent the experiences of people from ethnic minorities.
The credibility of the work may have been affected by the respondents inability to accurately recall
their perceptions of various events and responses to
those events. Therefore, we developed theory based
on patients perceptions of what they had actually
experienced.

CONCLUSION
Figure 1 is a model of the theory developed from this
study. From the participants reports the picture was
one of patients suffering from continuous pain from
the moment of ulcer development; they did not have
their pain assessed, and the etiology of their pain
was not determined. The patients continued to suffer
pain which became as chronic as the leg ulcer and
led them to develop a chronic pain condition associated with the leg ulceration. This study provides an explanation of why the participants described having
chronic pain with its associated sequelae. The treatment they were receiving to heal the ulcer in some
cases exacerbated their pain. Once the participants
had developed a chronic pain condition, their quality
of life was compromised. They suffered from chronic
pain and described adverse sequelae, including insomnia, depression, social isolation, suicidal ideation, and
a desire for limb amputation. The participants in this
study described a pain experience that represented
a chronic pain condition.

IMPLICATIONS FOR CLINICAL


PRACTICE
The pain associated with the chronic leg ulcer was reported to be as chronic as the leg ulcer itself. Leg ulceration is a chronic condition; therefore, if the pain from
leg ulceration is not managed, patients risk developing
a chronic pain condition. These patients required

196

Taverner, Closs, and Briggs

chronic pain management that considered the etiology


of the pain. Perhaps it would be more appropriate to
manage these patients using a symptom management
approach as well as a healing approach, which would
enable pain management rather than exacerbating it.
This would allow a shift of care that would ensure
that patients pain is assessed and treated

appropriately, with the aim of creating a better quality


of life for the patient.
Acknowledgments
This study could not have taken place without input from
patients who suffer pain associated with leg ulceration; the
authors are deeply indebted to them.

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