Original Article Management of Pain and Quality of Life in Patients with Chronic Kidney Disease Undergoing Hemodialysis ---

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From the *Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Sparta, Lakonia, Greece; †General Hospital of Thoracic Diseases, Athens, Attiki, Greece. Address correspondence to Victoria Alikari, RN, MSc, PhD(c), Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Efstathiou & Starmatikis Valioti &., 23100 Sparta, Lakonia, Greece. E-mail: [email protected] Received March 15, 2015; Accepted March 17, 2015. 1524-9042/$36.00  2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2015.03.004

Sofia Zyga, PhD,* Victoria Alikari, RN, MSc, PhD(c),* Athanasios Sachlas, PhD,* John Stathoulis, BSc, MSc, PhD(c),* Adamantia Aroni, RN, MSc, PhD(c),* Paraskevi Theofilou, PhD,† and Georgios Panoutsopoulos, PhD*

ABSTRACT:

An important dimension that influences the quality of life of hemodialysis patients is the pain they experience. Quality of life and selfefficacy in pain can play an important role in chronic kidney disease and treatment outcomes. The purpose of the study was to examine self-efficacy in pain and quality of life among patients with end stage renal disease undergoing hemodialysis. Between April 2013 and June 2013, 224 hemodialysis patients completed the Missoula-VITAS Quality of Life Index-15 and the Pain Self-Efficacy Questionnaire. The study was conducted in four dialysis units in hospitals of the Peloponnese region. Sociodemographic data of patients and their individual medical history were recorded. Statistical analysis was performed using SPSS version 19. The more effective the self-efficacy in pain, the lower the quality of life enjoyed by hemodialysis patients. The majority of respondents described the overall quality of life as ‘‘moderate,’’ while the self-efficacy in pain depended on comorbidity or complications that accompany the process of hemodialysis. The findings of this study can be used in the development and improvement of health services for the management of patients. Healthcare professionals should understand the concerns and treat the symptoms of patients that affect quality of life, providing thereby holistic health care.  2015 by the American Society for Pain Management Nursing

INTRODUCTION Chronic kidney disease (CKD) is a chronic disease that can have serious effects on the quality of life (QoL) of patients and, in particular, on their social, Pain Management Nursing, Vol -, No - (--), 2015: pp 1-9

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economic, and psychological prosperity. Consequently, an increased interest in the QoL of hemodialysis (HD) patients is observed (Theofilou & Panagiotaki, 2010; Theofilou 2012; Theofilou 2013a; Theofilou 2013b; Theofilou, Aroni, Ralli, Gouzou, & Zyga, 2013). Significant developments that have been made in recent years on dialysis methods have contributed significantly to the increased survival of patients with end stage renal disease (ESRD) (Morsch, Goncalves, & Barros, 2006). The diagnosis of CKD radically upsets the life of the individual and the family. Apart from the health problem, the patient has to confront complex psychological and social problems that affect relationships, roles, activities, and life pursuits (Theofilou 2011).

BACKGROUND Each episode of pain is a particular personal experience for the patient and is affected by physical, psychological, cognitive, socioformative, and religious factors. Pain is usually equated with illness, and is the most common cause for seeking medical care (Miller & Newton, 2006). Pain is the subjective response of the body to physical and psychological stress factors and is defined as an ‘‘unpleasant sensory and emotional experience associated with actual or potential tissue damage’’ (Loeser & Treede, 2008). Effect of Pain on Quality of Life All people have experienced pain at some point in their lives. Although pain is considered to be unpleasant and undesirable, it plays a protective role for the body and serves as a warning for health-threatening situations (Gebhart, 2000). Pain is one of the most common symptoms for ESRD patients with induced severe disruption of their QoL (Calls et al., 2009). Pain may have a negative impact in many areas of a patient’s life, including mental status and ability to respond to his or her daily social role (Iacono, 2003). A patient’s survival and QoL depend on the periodic correction of biological parameters by the appropriate technical assistance. This situation affects both the patient and his or her environment (Theofilou, 2011). Pain in Kidney Disease Hemodialysis patients experience extensive physical discomforts. Pain is a frequent symptom reported among HD patients, although it is not an extremely common subject of research among this population. In particular, information on its origin, incidence, and management is relatively rare. Most published data are derived indirectly from studies focusing on health related to QoL (Davison, 2003; Mercadante et al.,

2005; Shayamsunder, Patel, Jain, Peterson, & Kimmel, 2005). The possible factors of pain are varied, including diabetic neuropathy and surgery related to vascular access. The etiology of pain in these patients as a symptom can be associated with either the disease that is responsible for the CKD (e.g., kidney cavitation, diabetes mellitus); a function of the technique or direct complications of the dialysis procedure (e.g., surgery for the creation of vascular access, puncture, cramps), a function of the late complications of the disease (e.g., renal osteodystrophy) or psychological effects of the disease and its treatment (Murtagh, Addington-Hall, & Higginson, 2007). Measures of Pain Pain measurement may be used for diagnostic purposes, for therapeutic approaches, or for assessing the effectiveness of a treatment (Hagger & Orbell, 2003). There are many reliable and valid pain assessment methods, which are based on self-report. These tools may include questionnaires or scales and separation based on the specific elements they measure. Most of these tools measure pain intensity, effect of pain, or other aspects of pain. The visual analogue scale (VAS), numerical rating scale (NRS) and verbal rating scale (VRS) are unidimensional measures of pain intensity. They are used for the adult population, including those with rheumatic diseases. VAS and VRS are, also, used to assess pain affect (Haefeli & Elfering, 2006; Von Korff, Jensen, & Karoly, 2000). The McGill Pain Questionnaire (MPQ) and the short-form McGill Pain Questionnaire (SF-MPQ) are multidimensional pain questionnaires designed to measure the emotional and evaluative aspects of pain and intensity in adults with chronic pain. The Chronic Pain Grade Scale (CPGS) assesses two dimensions of overall chronic pain severity: intensity and pain-related disability. It is used in all chronic pain conditions, including chronic musculoskeletal and low-back pain. The short-form 36 Bodily Pain Scale (SF-36 BPS) is one of eight subscales of the Medical Outcomes Study SF-36 Questionnaire for use in population surveys. Version 2.0 of the SF-36 BPS assesses bodily pain as a dimension of health status. The Wisconsin Brief Pain Questionnaire is a selfreport instrument designed to assess pain in cancer and other diseases. It assesses pain intensity and pain interference. The Memorial Pain Assessment Card (MPAC) measures the intensity of pain, the palliation of pain, and psychological discomfort using three visual analogue scales in combination with lists of words from which the patient selects those that describe the intensity of pain (Hawker, Mian, Kendzerska, & French, 2011; Von Korff et al., 2000). The Minnesota

Pain and Quality of Life in Hemodialysis

Multiphasic Personality Inventory-2 (MMPI-2) is the most frequently used assessment tool for evaluating the characteristics of the personality in patients suffering from chronic pain (Arbisi & Butcher, 2004).

METHODS Aim The aim of the study was to evaluate pain self-efficacy and QoL in patients undergoing hemodialysis. Design The study adopts an analytic study design. Participants All 230 patients on maintenance HD from four hospital units in the broader area of Peloponnese were asked to take part in this study. The inclusion criteria were (a) aged older than 18 years; (b) ability to speak, write, and read in Greek; and (c) having undergone hemodialysis treatment for at least 1 year. The exclusion criteria were (a) patients with history of psychiatric illness and (b) patients with serious mobility or eye problems. Of the 230 possible participants, 224 met the criteria. The study was conducted from April 2013 to June 2013. Data Collection Data were collected using anonymous questionnaires. Subjects participated in the study were given two questionnaires. The first part contained questions related to sociodemographic data and data from personal history, followed by the Greek version of the Missoula-VITAS Quality of Life Index-15 (MVQOLI-15) (Theofilou, Kapsalis, & Panagiotaki, 2012). The MVQOLI-15 is an assessment tool that collects reports and information from patients on their QoL during an advanced disease. The questionnaire consists of five dimensions: symptoms, functionality, interpersonal relationships, wellness, and spirituality. In each area, three types of information are collected regarding (a) assessment (subjective measurement of the actual situation or circumstance), (b) satisfaction (degree of acceptance or knowledge of the actual situation), and (c) importance (the degree to which a given dimension has an impact on the overall quality of life). The questions are general and responses use a five-point scale (Likert), so that the lowest score indicates the least desirable condition and vice versa. The MVQOLI items are scored as follows: assessment: 2 to þ2; satisfaction: 4 to þ4; and importance: 1 to 5. The following equation is used to determine the total score in each dimension: (assessment þ satisfaction) x importance. The assessment and satisfaction scores can range from 6 to þ6

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and indicate whether the patient assesses his or her situation positively or negatively. When multiplied by the importance factor, the overall dimension score is magnified by how important that domain is. The final score in each dimension reflects the overall impact of that domain on quality of life. The internal validity of the Greek version of the questionnaire was satisfactory with Cronbach’s alpha of 0.74. (Theofilou et al., 2013). In addition, patients were given the pain selfefficacy questionnaire (PSEQ), which explores and evaluates the patient’s self-efficacy to perform normal activities and have a proper individual, family, and social life despite the presence of chronic pain. The original PSEQ (Tonkin, 2008) was created in 1980 by Michael Nicholas and consists of 10 questions. It has been used in Portuguese patients with chronic musculoskeletal pain (Knobel et al., 2002) and in Chinese patients with chronic pain under physiotherapy (Arenas et al., 2010). It takes 2 minutes to complete. Responses range from 0 (not at all confident) to 6 (completely confident). The total score is determined by summing the responses on the 10 questions; therefore, the score ranges between 0 and 60. A high score indicates greater selfefficacy in pain (Tonkin, 2008). Psychometric properties of the Greek version have been tested, with a Cronbach’s alpha of 0.98 (Theofilou et al., 2014). This is the first time PSEQ has been used in HD patients. Ethical Considerations This research study has complied with the fundamental ethical principles that govern the conduct of research. In particular, full confidentiality was kept with respect to information regarding the participants and the safety of the material was retained, the anonymity of the participants was protected, and the results obtained were used solely for the purposes of this research. The study was approved by the Scientific Councils of the General Hospitals of Sparta, Molaoi, and Messenia.

DATA ANALYSIS The descriptors of variables were examined and analyzed. We used the basic measures of position and dispersion, and the frequencies and relative frequencies, to describe the demographic characteristics and aspects of quality of life of patients and selfefficacy in pain. In order to investigate the research hypotheses of this study, questions were used from the questionnaire scale (Missoula-VITAS Quality of Life Index) for the synthesis of individual scores (aspects) of QoL. The scores were categorized as symptoms, functionality, interpersonal relations, wellness, and spirituality. In addition,

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the PSEQ was used to examine patient-reported self-efficacy. Statistical Methods For benchmarking the quality of life and self-efficacy in pain with the basic demographic characteristics, analysis of variance was applied in one direction (ANOVA F-test); comparison of the average value between two independent samples (t-test) and the correlation coefficient Spearman r were calculated. These same tests were performed to determine the statistical correlation between quality of life and self-efficacy in pain with the health history and treatment with dialysis. Finally, the statistical correlation of overall quality of life in patients with CKD on dialysis treatment and pain was performed by calculating the correlation coefficient Spearman r. A p value of less than .05 was considered statistically significant. To perform the statistical analysis, SPSS version 19 (SPSS Inc., 2003, Chicago, USA) was used.

RESULTS Participant Characteristics In this study, 224 HD patients participated. Of these patients, 54.9% were male and 45.1% female, while 42.0% were aged between 41 and 60 years of age (mean age ¼ 59.75 years). See Table 1 for additional demographic data. Regarding medical history, 49.6% of patients were on hemodialysis for up to 5 years; 91.1% had undergone surgery, with 89.7% of these surgical interventions performed to create vascular access. As for coexisting diseases, diabetes mellitus (33.0%), hypertension (62.1%), heart diseases (39.7%, with 71.9% of those suffering from coronary heart disease), and bone disease (21.0%) are mentioned. Also, 24.6% of patients indicated mobility problems. During hemodialysis session, patients mentioned suffering from cramps (61.2%), headache (54.9%), or itching (33.9%). The basic descriptive measures of location and dispersion of the five dimensions of QoL are presented in Table 2. The dimension ‘‘interpersonal relationships’’ seems to have the highest mean (11.5  11.28); ‘‘functionality’’ (5.7  10.92) and ‘‘symptoms’’ (3.0  7.45) follow. ‘‘Spirituality’’ and ‘‘wellness’’ had negative means (8.9  11.61 and 7.3  9.81, respectively). At the same time, on the question, ‘‘How would you rate the overall quality of your life?’’, the answers are shown on Table 3. According to the findings of the study, the mean of self-efficacy in pain among HD patients is neutral (Table 4).

TABLE 1. Participant Demographics Demographic Data

Frequency

Gender Female Male Age (years) 21 – 40 41 – 60 61 – 80 >81 Marital status Married Unmarried Divorced Widowed Number of children None 1 2 3 >3 Educational level Primary School Secondary School University Type of employment Full time Part time Unemployment Pensioner Housework Family income (Euro/month) 0 – 500 501 – 1000 1001 – 1500 >1501 Did not answer

Percentage

101 123

45.1 54.9

27 94 78 25

12.1 42.0 34.8 11.2

142 39 19 24

63.4 17.4 8.5 10.7

57 31 74 33 29

25.4 13.8 33.0 14.7 12.9

102 76 46

45.5 33.9 20.5

22 32 20 108 42

9.8 14.3 8.9 48.2 18.8

34 28 15 3 144

15.2 12.5 6.7 1.3 64.3

Correlations Table 5 shows the results of statistical correlation of the overall QoL score and self-efficacy in pain of HD patients. For this purpose, the Pearson’s correlation

TABLE 2. Basic Statistical Measures of the Five Dimensions of Quality of Life Score

Mean

SD

Minimum Maximum

1. Symptoms 2. Functionality 3. Interpersonal relationships 4. Wellness 5. Spirituality

3.0 5.7 11.5

7.45 10.92 11.28

16.0 30.0 30.0

30.0 30.0 30.0

7.3 8.9

9.81 11.61

30.0 30.0

30.0 30.0

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Pain and Quality of Life in Hemodialysis

TABLE 3. Descriptive Statistics of Overall Quality of Life How Would you Rate the Overall quality of Your Life? Very poor Poor Moderate Good Very good

Frequency

Percentage

9 20 98 87 10

4.0 8.9 43.8 38.8 4.5

coefficient r was calculated. Findings suggested a statistically significant correlation between overall QoL and self-efficacy in pain. Specifically, the more effective the self-efficacy in pain, the lower QoL of patients as regards the overall QoL for patients with CKD (r ¼ 0.315, p value < .001). Gender affects neither self-efficacy in pain [t(222) ¼ 0.667, p ¼ .506] nor QoL [t(222) ¼ 0.794, p < .428]. Age affects self-efficacy in pain [KruskalWallis c2(3) ¼ 37.214, p < .001] and QoL [KruskalWallis c2(3) ¼ 20.746, p < .001]: The greater the age of patients, the less self-efficacy in pain. Conversely, younger patients (21–40 years old) had lower quality of life (mean ¼ 13.3) compared with older patients (61–80 years old) (mean ¼ 13.4). Self-efficacy in pain is affected by mobility problems [t(222) ¼ 9.708, p < .001], hypertension [t(222) ¼ 4.786, p < .001], heart disease [t(222) ¼ 6.158, p < .001], and bone disease [t(222) ¼ 6.158, p < .001], as well as cramps [t(222) ¼ 3.358, p ¼ .001], headache [t(222) ¼ 4.965, p < .001], and itchiness [t(128.182) ¼ 5.154, p < .001] during the HD session. Patients who had mobility problems (mean ¼ 18.7); suffered from hypertension (mean ¼ 29.1), heart disease (mean ¼ 27.6), and bone disease (mean ¼ 21.9); or experienced cramps (mean ¼ 30.0), headaches (mean ¼ 28.4) and itchiness (mean ¼ 25.6) during the HD session seemed to manage pain in a less-effective way. Self-efficacy in pain was also affected by marital status [Kruskal-Wallis c2(3) ¼ 34.419, p < .001],

TABLE 4. Basic Statistical Measures for the Self-Efficacy in Pain Score Score

Mean

SD

Minimum

Maximum

PSEQ

32.5

14.43

0

60

SD ¼ standard deviation.

TABLE 5. Results of Statistical Correlation of Overall Quality of Life and Self-Efficacy in Pain Score

Correlation Coefficient r

p Value

PSEQ – MVQOLI

0.315

.05). We also found that diabetic patients or patients without heart disease enjoy lower QoL, while those with hypertension enjoyed better QoL but were less effective in managing pain. Similar results were found by Mujais et al. (2009), highlighting both diabetes mellitus and heart disease as factors of low QoL. The high burden of physical and psychological symptoms is multifactorial, and in this study was associated with decreased daily activity and a significant impact on QoL and independence. Several researchers (Harris et al., 2012, Perlman et al., 2005) have also shown that pain negatively impacts many fields of QoL, including physical function, social function, daily activities, energy, fatigue, and emotional function. Gamondi et al. (2013) found that 75% of the participants reported that pain restricts fully or partially their daily activities. Furthermore, Davison (2010) emphasizes the strong negative correlation between the total burden of symptoms and QoL related

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to either the physical or mental health. Finally, Davison and Jhangri (2005) showed that chronic pain is significantly associated with depression and insomnia, as well as the desire to withdraw from the HD procedure.

LIMITATIONS OF THE STUDY As already mentioned, the survey was conducted in four hemodialysis units of the Peloponnese region of Greece. Therefore, it is not possible to generalize the results for all patients undergoing HD. The results would be more reliable and possibly differentiated if the sample size was larger and the geographic distribution wider. Also, because the questionnaires were completed during the course of treatment, the presence of medical staff and other patients may have influenced the objectivity of the responses. However, it should be noted that even though the results are based on the subjective perception of patients, their agreement for the most part with the published bibliography limits the bias and lack of objectivity greatly.

IMPLICATIONS FOR PRACTICE Having researched similar studies and bibliographic data, we propose the organization and implementation of educational programs at regular intervals for healthcare professionals working in hemodialysis units to enable them to recognize and evaluate implementation scales of self-efficacy in pain among patients undergoing HD. We also suggest the creation of interdisciplinary teams in order to shift the focus of care from only the medicinal side of treatment to one that includes the broader aspects of physical, mental, and social health. Doctors, nurses, psychologists, social workers, and physical therapists should be part of these teams. There is a need for the creation of assessment protocols of self-efficacy in pain that rely on international clinical guidelines, documented procedures, and valid and reliable scientific information. Encouragement of patients to selfassessment and self-efficacy in pain, such as taking the correct medication or for applying techniques of pain relief, is necessary. Health staff should encourage externalizing thoughts and feelings, as knowing the personal beliefs and experiences of each patient is necessary to understand the reactions of the patient and the intensity of pain. Fear and potential negativity on the part of a patient about the disease and its course, lack of support from family, and patients’ tendency to exaggerate their symptoms are factors that must also be considered. Providing these patients with appropriate psychological support can decrease

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the intensity of their symptoms. It is essential that healthcare providers collaborate with the patient’s immediate family to understand the patient’s personality so that it can be assessed and used in combination with the pain management plan. Continuous evaluation of the analgesic results, both in reducing symptoms and improving the QoL level, based on pain scales is imposed. Ultimately, research should be expanded on this subject for secure and reliable results, with the ultimate purpose of relieving this particular group of patients from severe and distressing symptoms such as pain, while improving their living conditions.

CONCLUSIONS Through the study of the psychometric properties of the PSEQ (Theofilou, 2014) and the study of the

psychometric properties of the MVQOLI (Theofilou et al., 2013), their validity was found to be highly satisfactory. Also, the fact that almost all patients responded with eagerness and ease to the questionnaires shows that they are easy tools and appropriate for use in studies. For these reasons, therefore, widespread use in future studies of similar content is suggested, both for the MVQOLI-15, which collected reports and information from patients about their QoL, and the PSEQ on the assessment of selfefficacy in pain.

Acknowledgments We thank hemodialysis patients, nursing staff, and the Scientific Councils of the General Hospitals of Sparta, Molaoi, and Messenia.

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Management of Pain and Quality of Life in Patients with Chronic Kidney Disease Undergoing Hemodialysis.

An important dimension that influences the quality of life of hemodialysis patients is the pain they experience. Quality of life and self-efficacy in ...
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