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Changing the way we think about wounds: A challenge for 21st century medical practice

Dear Editors, In the UK alone, more than £5 billion is spent each year on treating leg ulcers and other types of wounds, yet the number of people chronically affected by non-healing wounds continues to rise. As the prevalence of chronic illnesses such as diabetes increases, so will the wounds associated with them. Whilst some risk factors for wounds are fixed (eg, age and sex), the majority are linked to behavioural lifestyle factors such as exercise and smoking. Indeed, more than 60% of the risk factors for chronic illnesses are due to modifiable factors and health psychology is fundamental to understand how psychology contributes directly and indirectly to the cause, progression, experience and outcomes of any physical illness. Moreover, early detection is an important predictor of recovery from wounds so patient empowerment and good staff–patient relationships are key for successful wound management. Research has identified a range of problems that exist as a result of having a wound, but what we have yet to fathom are complex ways in which causative factors interact to produce a more or less favourable outcome for patients. Regardless of the origin of the wound, whether it is a venous leg ulcer or a diabetic foot ulcer, shared factors must determine different wound outcomes. We know that some people appear genetically susceptible to non-healing or therapy-resistant wounds due to individual differences in their immunity and healing rate. Other individual differences such as personality traits could also predict poor wound healing. For example, low conscientiousness has been found to be the best predictor of disease burden, progression, and severity in various illnesses including diabetes and skin problems. It is likely that conscientiousness holds its dominant influence over health outcomes as high levels of this trait acts as a protective factor against stress, an influential factor in delayed wound healing. Behavioural influences on illness outcomes include patient control and coping mechanisms such as self-examination and help seeking. However, the very language that we use ‘wound care’ and the focus of prior research suggests symptoms to be managed by a third party rather than empowering the patient to self-care. A joint review of the guidelines for treating venous leg ulcers highlights that patients and their caregivers can play a proactive role in self-care but negligible reference is made to how they might be empowered to do this. Wound research has failed to recognise that not only does physical health influence our mental health but also our psychology affects our physical health. Through interdisciplinary research we can turn the way that we think about wounds on its head by moving away from the traditional nurse-led (symptom management) approach to a more patient-centred approach. Our aim is to lobby for the adoption of a novel approach to understand the complex relationships among various underlying causes of different health and illness outcomes for people with wounds. While we have been debating this biopsychosocial approach to health in the literature for more than 40 years, we are still some way off translating our academic discussions into new advances in wound treatment. A radical transformation away from the overriding biomedical paradigm is the likely solution to these global wound management issues. While nominally acknowledging the mind–body connection, research currently fails to comprehend, or translate into practice, the complex inter-relationships that exist among the diverse factors associated with wounds. There is an appreciation that multiple factors contribute to wound care issues but there is little clarity about the mechanism of that interaction. Currently, little has been explored on the psychological and cognitive mechanisms that influence the wound onset, and we know even less about individual differences in susceptibility to non-healing wounds. Engagement with the biopsychosocial approach would allow for a comprehensive and person-centred approach to the complexity of the mind–body connection. This timely, critical, and comprehensive approach to chronic wound management is ambitious, yet leads to new concepts that would pave the way for novel regimes, fresh ideas, and modern treatment packages for patients with wounds. Based on health psychology principles, this can be achieved through new research that guides the organisation and delivery of multidisciplinary health services so that the maximum benefit is felt by patients, the community, and the overstretched National Health Service. Our main challenge is likely to be in utilising research findings in the designing Received: 24 October 2017 Accepted: 30 October 2017