The purpose of this study was to explore the personal experience of pain among Greek patients undergoing Renal Replacement Therapy with Haemodialysis and Peritoneal Dialysis, and to record the methods of pain self-management used. To the main researcher’s knowledge there was no research on renal patients’ experience of pain conducted in Greece at the time the present research dissertation started (beginning of 2010), eventhough the topic was researched in Europe and the rest of the world since the late 1990s. The main findings can be synopsed in that approximately one third of the participants experienced high levels of pain and that haemodialysis patients were more in pain than peritoneal dialysis ones.
Furthermore, it was found that all patients used a means to relieve pain, either local application of warmth and massage, walking or consumption of medications.
In more details, eight out of ten patients were on haemodialysis, with a mean age of 68.8 (±13.2) years old and more than half were males (56.7%). Demographic characteristics regarding mode of therapy and age have been found to exceed Greece’s average (74.2% on haemodialysis and 62.8 years old, respectively). Whereas in the gender parameter, male dialysis patients were fewer than Greece’s average (63.5% males) as they are presented by Ioannidis & Papadaki (2013). In the present study a positive correlation between time on dialysis and pain was observed, which is in accordance with other published studies that report the same trends (Davison 2003, Golan et al. 2009).
Globally, patients with Chronic Kidney Disease have been found to have high scores of bodily pain (more than 48%) compared to general population, in which pain ranged from 2%
to 45% (Diaz-Buxo et al. 2000, Catala et al. 2002, Hasselstrom et al. 2002, Bailie et al. 2004, Weisbord et al. 2005). This variability in rates may be due to differentiations in the definition of pain, in the perception of pain among diverse population studied, in research methods or the use of different pain measurement tools, such as the Brief Pain Inventory (BPI) or the McGill Pain Questionnaire (MPQ) (Weisbord et al. 2005, Figueiredo et al. 2008, Golan et al.
2009). Furthermore, research data suggest that severe chronic pain in the general population ranges from 1% to 14% (Smith et al. 2001, Clark 2002), whereas in renal population a recent systematic review reports a range between 3.3/10 to 5.6/10 in haemodialysis patients and 2.2/10 to 4.1/10 in peritoneal dialysis (Davison et al. 2014).
One sixth of the participants in the present study were found to have experienced severe pain and almost one fourth described it as horrible and excruciating. These findings are in accordance with the general population and a study by Golan et al. (2009) (19.6% reported severe pain), but significantly lower than the 81% of patients with pain values ≥8 in the VAS scale (Gamondi et al. 2013) or the 55% of severe pain sufferers in the dialysis population study by Davison (2003). In addition, the patients’pain levels were lower than the 50% in the study of Kimmel et al. (2003) or the 40.8% in the Yong et al. (2009) study. The severity of pain measured in this particular study was equal to cancer pain (Chang et al. 2000, Hwang et al.
2003, Davison et al. 2006) or to patients with Human Immunodeficiency Virus (Smith et al.
2002). In similar researches, pain was characterised either intense by six out of ten patients (Gamondi et al. 2013), or moderate to severe by four out of ten patients (Davison & Jhangri 2005, Barakzoy & Moss 2006).
12.1.1 Demographic and treatment data
A significant finding of the study was that as age progressed, the perception of pain experienced (in Visual Analogue Scales and in Wong-Baker pain rating scales) was more. In
the adaptation of WHO analgesic ladder to Chronic Kidney Disease patients (Barakzoy &
Moss 2006) it was found that older patients had higher scores of pain, reaching 50% and 82%
of which rated pain as moderate to severe (Shayamsunder et al. 2005, Davison 2007a). Similar are the findings in general population as well as in community settings (Catala et al. 2002, Clark 2002, Hasselstrom et al. 2002). Furthermore, two other studies in Greek dialysis population conducted in Athens region concluded that younger patients (under 40 years old) seemed to achieve better pain self-efficacy than older ones (Theofilou 2012, Zyga et al. 2015a).
Our findings are contradictory to the findings of Lovering (2006), who in a study of multicultural healthcare professionals and patients’ perception of pain in Saudi Arabia concluded that younger and richer persons tolerate pain less than older and poorer, maybe due to different cultural background of the populations. In addition, Davison & Jhangri (2010), in Alberta, Canada, and Calls et al. (2009) in Mallorca, Spain, found no statistically significant differences between pain assessment and age or gender.
In the 19th century it was believed that there was a variation in the perception of pain according to racial groups; females, whites and rich were regarded as being more sensitive to pain than males, criminals, African and Native Americans, who were considered to be
“virtually impervious to physical trauma” (Lash 2002, Etienne 2006). Gender differences in the perception of pain are reported in a number of studies, indicating that women are more sensitive to painful stimuli than men (Lasch 2002, Dysvik et al. 2004, Greenspan et al. 2007, Figueiredo et al. 2008, Khan et al. 2015) whereas others report no difference at all (Moore et al. 2013). It has been suggested that sex hormones and the endogenous opioid system are some sources of pain-related variability (Bartley & Fillingim 2013). Vincent et al. (2013), in a study of general population, found that, during brain imaging, women using low on testosterone oral contraceptives, had reduced pain-related activation in pain inhibitory brain regions and concluded that females are more tolerant to painfull stimuli.
In our study the results showed a difference in the perception of pain between genders, but it did not have the same trend in the different scales used. In the Wong-Baker scale males reported higher pain levels (“hurts even more” for one third), whereas in the Visual Analogue Scale females marked higher (6.07±1.85), maybe due to the nature of the research tool. In addition, male patients described more bodily parts as painful, compared to females who complained only for two painful body areas. As perception of pain can be influenced by social and cultural beliefs; it is expected of women to express their feelings, including pain, more openly than men. Furthermore, it has been proven that women are more sensitive to pain during menstruation; alas our patients in productive age were very few. Research, both in general population as well as in renal patients, has proven that women experience pain more frequently and with increased intensity than men (Toblin et al. 2011, Davison 2015). Finally, men are usually discouraged to express their feelings, as this could be interpreted as weakness (Robinson et al. 2003, Figueiredo et al. 2008, Lin et al. 2015) and contrary to their “dominant” and “breadwinner” role in the society. In another study regarding Greek dialysis population, male patients were reported of having more social activities and better quality of life, due to less pain, than females (Theofilou 2012) contrary to our findings.
In a comparison between haemodialysis and peritoneal dialysis patients statistical significance was found (p<.001), with the first having a score in McGill pain questionnaire (PRI) of 45.4 (±13) and the latter 40.1 (±8.9). At the late ‘90s, in a multicentre study of Dutch dialysis population (Merkus et al. 1999) it was found that haemodialysis patients had more impaired quality of life and bodily pain than peritoneal dialysis population. In addition, patients on haemodialysis in a cross-sectional study of 821 Portuguese dialysis patients (Furctuoso et al. 2011) were found to experience higher bodily pain than peritoneal dialysis ones. Similar were the findings of Theofilou (2012) in a study in Greek dialysis population.
Contrarily, numerous studies have shown that the two modalities are similarly effective in terms of health-related quality of life (Kontodimopoulos et al. 2009, Harris et al. 2002). This
12 Discussion
12.1 MAIN FINDINGS
The purpose of this study was to explore the personal experience of pain among Greek patients undergoing Renal Replacement Therapy with Haemodialysis and Peritoneal Dialysis, and to record the methods of pain self-management used. To the main researcher’s knowledge there was no research on renal patients’ experience of pain conducted in Greece at the time the present research dissertation started (beginning of 2010), eventhough the topic was researched in Europe and the rest of the world since the late 1990s. The main findings can be synopsed in that approximately one third of the participants experienced high levels of pain and that haemodialysis patients were more in pain than peritoneal dialysis ones.
Furthermore, it was found that all patients used a means to relieve pain, either local application of warmth and massage, walking or consumption of medications.
In more details, eight out of ten patients were on haemodialysis, with a mean age of 68.8 (±13.2) years old and more than half were males (56.7%). Demographic characteristics regarding mode of therapy and age have been found to exceed Greece’s average (74.2% on haemodialysis and 62.8 years old, respectively). Whereas in the gender parameter, male dialysis patients were fewer than Greece’s average (63.5% males) as they are presented by Ioannidis & Papadaki (2013). In the present study a positive correlation between time on dialysis and pain was observed, which is in accordance with other published studies that report the same trends (Davison 2003, Golan et al. 2009).
Globally, patients with Chronic Kidney Disease have been found to have high scores of bodily pain (more than 48%) compared to general population, in which pain ranged from 2%
to 45% (Diaz-Buxo et al. 2000, Catala et al. 2002, Hasselstrom et al. 2002, Bailie et al. 2004, Weisbord et al. 2005). This variability in rates may be due to differentiations in the definition of pain, in the perception of pain among diverse population studied, in research methods or the use of different pain measurement tools, such as the Brief Pain Inventory (BPI) or the McGill Pain Questionnaire (MPQ) (Weisbord et al. 2005, Figueiredo et al. 2008, Golan et al.
2009). Furthermore, research data suggest that severe chronic pain in the general population ranges from 1% to 14% (Smith et al. 2001, Clark 2002), whereas in renal population a recent systematic review reports a range between 3.3/10 to 5.6/10 in haemodialysis patients and 2.2/10 to 4.1/10 in peritoneal dialysis (Davison et al. 2014).
One sixth of the participants in the present study were found to have experienced severe pain and almost one fourth described it as horrible and excruciating. These findings are in accordance with the general population and a study by Golan et al. (2009) (19.6% reported severe pain), but significantly lower than the 81% of patients with pain values ≥8 in the VAS scale (Gamondi et al. 2013) or the 55% of severe pain sufferers in the dialysis population study by Davison (2003). In addition, the patients’pain levels were lower than the 50% in the study of Kimmel et al. (2003) or the 40.8% in the Yong et al. (2009) study. The severity of pain measured in this particular study was equal to cancer pain (Chang et al. 2000, Hwang et al.
2003, Davison et al. 2006) or to patients with Human Immunodeficiency Virus (Smith et al.
2002). In similar researches, pain was characterised either intense by six out of ten patients (Gamondi et al. 2013), or moderate to severe by four out of ten patients (Davison & Jhangri 2005, Barakzoy & Moss 2006).
12.1.1 Demographic and treatment data
A significant finding of the study was that as age progressed, the perception of pain experienced (in Visual Analogue Scales and in Wong-Baker pain rating scales) was more. In
the adaptation of WHO analgesic ladder to Chronic Kidney Disease patients (Barakzoy &
Moss 2006) it was found that older patients had higher scores of pain, reaching 50% and 82%
of which rated pain as moderate to severe (Shayamsunder et al. 2005, Davison 2007a). Similar are the findings in general population as well as in community settings (Catala et al. 2002, Clark 2002, Hasselstrom et al. 2002). Furthermore, two other studies in Greek dialysis population conducted in Athens region concluded that younger patients (under 40 years old) seemed to achieve better pain self-efficacy than older ones (Theofilou 2012, Zyga et al. 2015a).
Our findings are contradictory to the findings of Lovering (2006), who in a study of multicultural healthcare professionals and patients’ perception of pain in Saudi Arabia concluded that younger and richer persons tolerate pain less than older and poorer, maybe due to different cultural background of the populations. In addition, Davison & Jhangri (2010), in Alberta, Canada, and Calls et al. (2009) in Mallorca, Spain, found no statistically significant differences between pain assessment and age or gender.
In the 19th century it was believed that there was a variation in the perception of pain according to racial groups; females, whites and rich were regarded as being more sensitive to pain than males, criminals, African and Native Americans, who were considered to be
“virtually impervious to physical trauma” (Lash 2002, Etienne 2006). Gender differences in the perception of pain are reported in a number of studies, indicating that women are more sensitive to painful stimuli than men (Lasch 2002, Dysvik et al. 2004, Greenspan et al. 2007, Figueiredo et al. 2008, Khan et al. 2015) whereas others report no difference at all (Moore et al. 2013). It has been suggested that sex hormones and the endogenous opioid system are some sources of pain-related variability (Bartley & Fillingim 2013). Vincent et al. (2013), in a study of general population, found that, during brain imaging, women using low on testosterone oral contraceptives, had reduced pain-related activation in pain inhibitory brain regions and concluded that females are more tolerant to painfull stimuli.
In our study the results showed a difference in the perception of pain between genders, but it did not have the same trend in the different scales used. In the Wong-Baker scale males reported higher pain levels (“hurts even more” for one third), whereas in the Visual Analogue Scale females marked higher (6.07±1.85), maybe due to the nature of the research tool. In addition, male patients described more bodily parts as painful, compared to females who complained only for two painful body areas. As perception of pain can be influenced by social and cultural beliefs; it is expected of women to express their feelings, including pain, more openly than men. Furthermore, it has been proven that women are more sensitive to pain during menstruation; alas our patients in productive age were very few. Research, both in general population as well as in renal patients, has proven that women experience pain more frequently and with increased intensity than men (Toblin et al. 2011, Davison 2015). Finally, men are usually discouraged to express their feelings, as this could be interpreted as weakness (Robinson et al. 2003, Figueiredo et al. 2008, Lin et al. 2015) and contrary to their “dominant” and “breadwinner” role in the society. In another study regarding Greek dialysis population, male patients were reported of having more social activities and better quality of life, due to less pain, than females (Theofilou 2012) contrary to our findings.
In a comparison between haemodialysis and peritoneal dialysis patients statistical significance was found (p<.001), with the first having a score in McGill pain questionnaire (PRI) of 45.4 (±13) and the latter 40.1 (±8.9). At the late ‘90s, in a multicentre study of Dutch dialysis population (Merkus et al. 1999) it was found that haemodialysis patients had more impaired quality of life and bodily pain than peritoneal dialysis population. In addition, patients on haemodialysis in a cross-sectional study of 821 Portuguese dialysis patients (Furctuoso et al. 2011) were found to experience higher bodily pain than peritoneal dialysis ones. Similar were the findings of Theofilou (2012) in a study in Greek dialysis population.
Contrarily, numerous studies have shown that the two modalities are similarly effective in terms of health-related quality of life (Kontodimopoulos et al. 2009, Harris et al. 2002). This
diversity of findings could be attributed to the research tools, methodology approach or the actual sample size.
12.1.2 Localisation of pain
Nine out of ten patients in our study reported that pain was focused on the upper and lower extremities and its origin was, mainly, musculoskeletal. Gamondi et al. (2013) reached the same conclusions, as he reports that lower and upper limbs are the most painful parts of a patients’ body according to their personal perception. In the general population musculoskeletal pain is mainly limited in the lower-back area, whereas in Chronic Kidney Disease patients, it is focused on joints due to dialysis-related arthropathy or renal osteodystrophy (Davison 2003, Golan et al. 2009). Hyperparathyroidism may act synergistically to osteoarthritis and cause bone and joint pain, contributing to the high prevalence of musculoskeletal pain in dialysis patients. Furthermore, Dialysis-Related Amyloidosis (DRA), a complication that can appear in both modes of Renal Replacement Therapy, can be manifested mainly in patients who are on dialysis for more than 15 years (Tran et al. 2001). B2-microglobulin deposits are gathering in bones, joints, tendons and peripheral nerves causing painful conditions such as cystic bone lesions, carpal tunnel syndrome, arthritis and periarthritis as well as spondyloarthropathy (Niwa 2001, Kelly et al.
2007).
Regarding pain of external origin, when patients were asked to rank pain caused by external forces or interventions, the most common problem affecting almost nine out of ten haemodialysis patients was pain in the vascular access area, fistula or graft. Haemodialysis treatment, usually performed three times a week, requires approximately 320 punctures of the vascular access per year, at least two per session. Repetitive needling of the vascular access causes fear, anxiety and discomfort, in addition to considerable pain due to the width and length of the bevel of the fistula needles (Figueiredo et al. 2008, Beghari-Nesami et al.
2014) which tear at the nerve ends receptive to pain (Montero et al. 2004). Similar were the findings of Golan et al. (2009) who stated that 80.2% of their patients reported some degree of pain during needling, with 40.6% characterising it as quite intense. In another study by Aitken et al. (2013) in 461 haemodialysis patients in West Scotland, one fourth reported severe pain during cannulation and 11.3% of them cut short the dialysis session due to pain.
Brachiobasilic arteriovenous fistulae have been associated with the highest incidence of severe pain, as a result of scarring from superficialisation and deep tissue injury with cannulation (Koncicki et al. 2015). Montero et al. (2004) suggested that cannulations should be performed with bevel of the fistula needle facing downwards, as this way is producing shorter transversal cuts, resulting in less pain and skin lesion at the point of the puncture.
Local anaesthetic creams have been successfully used prior to venepuncture on intact skin and could be easily used (Benini et al. 1998, Sawyer et al. 2009). Attention should be given in the time of application, as the cream needs 45-60 minutes to be absorbed into the subcutaneous tissue and achieve the maximum of its anaesthetic capacity (Koncicki et al.
2015). An alternative method to creams is the use of volatile liquid sprays (ethyl chloride, fluorohydrocarbon etc) which are chilling, by evaporation, the exact skin surface planned to be punctured. Rapid evaporation of the spray causes decrease in temperature through desensitisation of pain receptors or inactivation of ion channels involved in pain transmission and finally results in temporary interruption of pain sensation (Sabitha et al. 2008, Page &
Taylor 2010).
12.1.3 Self-management interventions
It is noteworthy that all patients participating in the present study, adopted some measures regarding pain management, eventhough five of them in the WB scales reported that they did not experience any pain at all. Even patients with mild pain (5%) or pain of 2cm (mild
pain) in the VAS chose some pain self-management interventions. It is suggested that pain coping strategies are different between genders (Keogh et al. 2005, Bartley & Fillingimn 2013), eventhough it was not one of our findings. Males tend to use problem-focus tactics and behavioural distraction and females use more frequently emotion-focused techniques, positive self-statements, and social support (Keogh & Eccleston 2006, Fillingim et al. 2009, Racine et al. 2012a, Racine et al. 2012b). Furthermore, bearing in mind that one third of peritoneal dialysis patients and half of the haemodialysis experienced some kind of pain in the lower extremities, someone would imagine that walking would be quite difficult for them. Nevertheless, walking for short distance was the most favourable means of pain management for almost all the participants (91.6%, n=641). It was preferred by the 96.7%
(n=116) of PD and 90.5% (n=525) of HD patients. Researchers suggest that weight-bearing activities, such as walking, should be encouraged for dialysis patients, due to the positive
(n=116) of PD and 90.5% (n=525) of HD patients. Researchers suggest that weight-bearing activities, such as walking, should be encouraged for dialysis patients, due to the positive