Research Article: Assessment and Treatment of Pain during Treatment of Buruli Ulcer

Date Published: September 24, 2015

Publisher: Public Library of Science

Author(s): Janine de Zeeuw, Marike Alferink, Yves T. Barogui, Ghislain Sopoh, Richard O. Phillips, Tjip S. van der Werf, Susanne Loth, Bouwe Molenbuur, Mirjam Plantinga, Adelita V. Ranchor, Ymkje Stienstra, Christian Johnson.

Abstract: BackgroundBuruli ulcer (BU) is described as a relatively painless condition; however clinical observations reveal that patients do experience pain during their treatment. Knowledge on current pain assessment and treatment in BU is necessary to develop and implement a future guideline on pain management in BU.MethodologyA mixed methods approach was used, consisting of information retrieved from medical records on prescribed pain medication from Ghana and Benin, and semi-structured interviews with health care personnel (HCP) from Ghana on pain perceptions, assessment and treatment. Medical records (n = 149) of patients treated between 2008 and 2012 were collected between November 2012 and August 2013. Interviews (n = 11) were audio-taped, transcribed verbatim and qualitatively analyzed.Principal FindingsIn 113 (84%) of the 135 included records, pain medication, mostly simple analgesics, was prescribed. In 48% of the prescriptions, an indication was not documented. HCP reported that advanced BU could be painful, especially after wound care and after a skin graft. They reported not be trained in the assessment of mild pain. Pain recognition was perceived as difficult, as patients were said to suppress or to exaggerate pain, and to have different expectations regarding acceptable pain levels. HCP reported a fear of side effects of pain medication, shortage and irregularities in the supply of pain medication, and time constraints among medical doctors for pain management.ConclusionsProfessionals perceived BU disease as potentially painful, and predominantly focused on severe pain. Our study suggests that pain in BU deserves attention and should be integrated in current treatment.

Partial Text: Buruli ulcer (BU) is a Neglected Tropical Disease for which the World Health Organization (WHO) stressed the need to improve treatment [1]. BU remains endemic in areas in West Africa, especially in Benin and Ghana [2,3]. In Benin, prevalence rates between 5.4 and 60.7 per 10.000 inhabitants have been reported each year [4] while in Ghana, prevalence rates have fluctuated between 2.0 and 15.0 per 10.000 inhabitants [5]. BU destroys skin, subcutaneous fat, and sometimes bone [6]. Patients typically present with non-ulcerated lesions; papules, nodules, plaques or edema, or undermined ulcers [6,7]. Treatment entails antibiotics complemented with surgery if needed, together with dressing changes of which the frequency depends on the wound, and physiotherapy [8]. Specialized treatment centers deliver the necessary care while antimicrobial treatment and dressings may also be delegated to local health centers [9]. Irrespective of therapy (antibiotics or surgery), 47% of patients are left with functional limitations after healing [10].

This study aimed to explore current pain practice in BU in Ghana and Benin. For most BU patients, pain medication was prescribed, and pain management mainly focused on severe pain. Professionals perceived later stages of BU as painful, and reported an increase in pain after wound treatment, and after a skin graft at the donor site. HCP reported a suppressed pain expression as well as exaggeration in patients, and differences in expectations between professionals and patients on what is an acceptable pain level without medication.



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