Physical methods of managing pain are considered to be all the techniques that evolve massage, therapeutic touch, acupressure, Alexander technique and use of herbs/phytomedicines.
Massage in the painful area can sometimes be possible by the person him/herself (e.g. pain in the arms or legs), but sometimes the help of another is required (e.g. back pain). Massage acts based on the Gate Control Theory, which can be easily described in simple words.
Massage stimulates fast-acting Aβ fibres, which go up the spinal cord in the dorsal horn.
Then they synapse in the same, quite restricted, area with pain-transmitting fibres (substantia gelatinosa). In the case of many nerve impulses arriving at the same time, some of them are blocked; they cannot pass through, reach the brain and create pain. Only the quick sensations, those travelling via the rapid Aβ fibres resulting from massage, can get through.
Therapeutic Touch is based on the belief that the body is surrounded by an aura (energy) which is in interaction with prana (universal energy, vital force) and is transformed by chakras (non-physical vortices). Illness and its symptoms appear when an energy imbalance, or else energy blockages, is present. The therapeutic touch practitioner, which can be healthcare professional, has been trained to quiet the mind, detach him/herself from inward and outward distractions and to pay full attention and intention on helping the patient.
Therapeutic touch has been reported to achieve relaxation and amelioration or eradication of pain in oncology patients undergoing chemotherapy (Aghabati et al. 2006) but it could be used in renal patients during painful procedures.
Acupressure is a massage technique during which the healer uses his/her fingers and palms, with some force, in order to stimulate acupoints and meridian lines on the surface of the skin of the patient. Its purpose is to balance and regulate the body energy (Qi), maintain or enhance health and prevent illness. It is used as a pain relief method, as by pressure various groups of nerve fibers are stimulated. These fibers activate the substantia gelatinosa, influencing the activities of T-cells that lead to painless stimulation of the brain, and alleviating pain by secretion of endorphins. Psychologically, the procedure stimulates the alpha waves of the brain to enhance relaxation (Cho & Tsay 2004). It is found that acupressure can enhance the quality of sleep (Tsay & Chen 2003), can help haemodialysis patients to relax, alleviate anxiety and pain (Tsay 2004).
A trained healer can train the patient in pain in the Alexander technique, an individualized approach by verbal instruction and hand contact, to improve postural tone and neuromuscular coordination. During the session continuous assessment of habitual musculoskeletal posture and special attention to the release of unwanted tension from head, neck and spinal muscles is provided. The goal of the technique is to allow decompression of the spine and improve posture (Little et al. 2008, Hogan & Norby 2010).
World Health Organisation has define traditional medicine as “health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being” (WHO 2014).
Herbal medicine is a form of complementary medicine, or else traditional medicine, as they are natural, and believed to be safe and effective (Marinac et al. 2007). Herbal products were used mainly in African and Asian countries, but in the last decade complementary products or herbal remedies are becoming popular in North America and Europe alongside the
“western” medicine (Izzo 2004, Kara 2009, Siponen et al. 2012).
Quite a lot of these phytomedicines are used to manage pain. Ηealthcare practitioners should have some knowledge of the potential interactions between herbal remedies and
conventional medications or their potential adverse effects on the presence of Chronic Kidney Disease. It has been proven that some herbal products should be avoided by renal patients as they cause progression of the established renal disease or have unpredictable and altered pahrmacokinetics. Aristolochic acid, used in Chinese herbal medicine, causes rapid interstitial nephritis and renal failure requiring dialysis or kidney transplantation and therefore it must be avoided. Barberry, a remedy to treat diarrhea, Buchu, a diuretic and anti-inflammatory plant and Juniper used for diabetes can cause nephritis and renal fibrosis.
Licorice consumed for liver diseases and Noni Juice used for diabetes and liver disease can cause water and electrolyte imbalance, such as sodium and water retention, hypo or hyperkalaemia (Kappel & Caliss 2002). On the other hand there are reported some benefits of herbal use in Chronic Kidney Disease patients, such as therapeutic effect on immune deficiency (Fanti et al. 2003), anaemia (Bradley et al. 1999), muscle cramps (Hinoshita et al.
2003) and sexual disorder (Liao et al. 1995).
6.2 PSYCHO-BEHAVIOURAL MODIFICATION METHODS
Psycho-behavioural modification methods to manage pain, on the other hand, include guided imagery, distraction and/or various relaxation techniques.
Guided imagery is a technique that teaches a person (patient) how to use its own imagination in order to divert their mental focus from a psychological and/or physiologic state, such as a painful procedure or a stressful situation, to more pleasant thoughts and relaxation. This self-administered technique is based on Gate Control Theory, which states that only one impulse can travel through the central nervous system at a time. If this route is blocked by pleasant thoughts, such as pictures of sea or fields, or friends, the painful stimuli cannot reach the brain to cause the perception of pain (Jurf & Nirschl 1993). Guided imagery can be further explained with the effect of endorphins. Relaxation increase endorphins, causing an increase in pain threshold and finally a decrease in pain perception.
Furthermore, the reduction of pain with increase of relaxation, and activation of parasympathetic nervous system resulting in a decrease in blood pressure, respirations and heart rate (Thomas 1991, McCance & Heuther 1998). This method could be problematic as the patient has to be able to focus for at least 20 minutes and to understand the process if he/she wants to implement it. It is important, during guided imagery, to minimise noises and interruptions, to teach the patient to take slow and deep breaths in order to achieve full concentration. Furthermore, exhaustion, sedation or emergency situations affect the patient’s ability to concentrate (Ackerman & Turkoski 2000). Guided imagery is a costless intervention and easy taught it encourages patients’ self-control and reduces the negative effects of medication therapy.
Another, similar to guided imagery, technique is distraction. It is also a self-administered technique that is widely used during venepuncture in children and adolescents. Windich-Biermeier et al. (2007) found that the effect of video games, puzzles or music tables on pain caused during venepuncture was positive. Furthermore, listening to music (live or from a CD player) or watching television reduces the perception of pain (Bellieni et al. 2006, Caprilli et al. 2007). These techniques are also used by dialysis patients without the patient being aware that they are using them. In most Dialysis Units in Greece the patients are encouraged to use their CD or DVD players or watch TV programmes during dialysis. It is a common practice for the Dialysis Unit to have installed television sets in every room, so that patient can spend more pleasantly their time. Unfortunately, these techniques if repeated on a regular basis can become unattractive and can lose their effectiveness.
Relaxation techniques with deep breathing exercises are a very easily taught method, and with no additional equipment cost. Relaxation techniques have a positive effect on anxiety and have proven effective in the management of pain in burn patients (De Jong & Gamel 2006). The patient is less anxious and therefore more relaxed, and the pain perception is diminished.
apply the best combination of conventional modalities and complementary strategies to enhance the biological, psychological, social and spiritual outcomes of the patient within the holistic model of care (Guzzetta 2010, Pham et al. 2010).
6.1 PHYSICAL METHODS
Physical methods of managing pain are considered to be all the techniques that evolve massage, therapeutic touch, acupressure, Alexander technique and use of herbs/phytomedicines.
Massage in the painful area can sometimes be possible by the person him/herself (e.g. pain in the arms or legs), but sometimes the help of another is required (e.g. back pain). Massage acts based on the Gate Control Theory, which can be easily described in simple words.
Massage stimulates fast-acting Aβ fibres, which go up the spinal cord in the dorsal horn.
Then they synapse in the same, quite restricted, area with pain-transmitting fibres (substantia gelatinosa). In the case of many nerve impulses arriving at the same time, some of them are blocked; they cannot pass through, reach the brain and create pain. Only the quick sensations, those travelling via the rapid Aβ fibres resulting from massage, can get through.
Therapeutic Touch is based on the belief that the body is surrounded by an aura (energy) which is in interaction with prana (universal energy, vital force) and is transformed by chakras (non-physical vortices). Illness and its symptoms appear when an energy imbalance, or else energy blockages, is present. The therapeutic touch practitioner, which can be healthcare professional, has been trained to quiet the mind, detach him/herself from inward and outward distractions and to pay full attention and intention on helping the patient.
Therapeutic touch has been reported to achieve relaxation and amelioration or eradication of pain in oncology patients undergoing chemotherapy (Aghabati et al. 2006) but it could be used in renal patients during painful procedures.
Acupressure is a massage technique during which the healer uses his/her fingers and palms, with some force, in order to stimulate acupoints and meridian lines on the surface of the skin of the patient. Its purpose is to balance and regulate the body energy (Qi), maintain or enhance health and prevent illness. It is used as a pain relief method, as by pressure various groups of nerve fibers are stimulated. These fibers activate the substantia gelatinosa, influencing the activities of T-cells that lead to painless stimulation of the brain, and alleviating pain by secretion of endorphins. Psychologically, the procedure stimulates the alpha waves of the brain to enhance relaxation (Cho & Tsay 2004). It is found that acupressure can enhance the quality of sleep (Tsay & Chen 2003), can help haemodialysis patients to relax, alleviate anxiety and pain (Tsay 2004).
A trained healer can train the patient in pain in the Alexander technique, an individualized approach by verbal instruction and hand contact, to improve postural tone and neuromuscular coordination. During the session continuous assessment of habitual musculoskeletal posture and special attention to the release of unwanted tension from head, neck and spinal muscles is provided. The goal of the technique is to allow decompression of the spine and improve posture (Little et al. 2008, Hogan & Norby 2010).
World Health Organisation has define traditional medicine as “health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being” (WHO 2014).
Herbal medicine is a form of complementary medicine, or else traditional medicine, as they are natural, and believed to be safe and effective (Marinac et al. 2007). Herbal products were used mainly in African and Asian countries, but in the last decade complementary products or herbal remedies are becoming popular in North America and Europe alongside the
“western” medicine (Izzo 2004, Kara 2009, Siponen et al. 2012).
Quite a lot of these phytomedicines are used to manage pain. Ηealthcare practitioners should have some knowledge of the potential interactions between herbal remedies and
conventional medications or their potential adverse effects on the presence of Chronic Kidney Disease. It has been proven that some herbal products should be avoided by renal patients as they cause progression of the established renal disease or have unpredictable and altered pahrmacokinetics. Aristolochic acid, used in Chinese herbal medicine, causes rapid interstitial nephritis and renal failure requiring dialysis or kidney transplantation and therefore it must be avoided. Barberry, a remedy to treat diarrhea, Buchu, a diuretic and anti-inflammatory plant and Juniper used for diabetes can cause nephritis and renal fibrosis.
Licorice consumed for liver diseases and Noni Juice used for diabetes and liver disease can cause water and electrolyte imbalance, such as sodium and water retention, hypo or hyperkalaemia (Kappel & Caliss 2002). On the other hand there are reported some benefits of herbal use in Chronic Kidney Disease patients, such as therapeutic effect on immune deficiency (Fanti et al. 2003), anaemia (Bradley et al. 1999), muscle cramps (Hinoshita et al.
2003) and sexual disorder (Liao et al. 1995).
6.2 PSYCHO-BEHAVIOURAL MODIFICATION METHODS
Psycho-behavioural modification methods to manage pain, on the other hand, include guided imagery, distraction and/or various relaxation techniques.
Guided imagery is a technique that teaches a person (patient) how to use its own imagination in order to divert their mental focus from a psychological and/or physiologic state, such as a painful procedure or a stressful situation, to more pleasant thoughts and relaxation. This self-administered technique is based on Gate Control Theory, which states that only one impulse can travel through the central nervous system at a time. If this route is blocked by pleasant thoughts, such as pictures of sea or fields, or friends, the painful stimuli cannot reach the brain to cause the perception of pain (Jurf & Nirschl 1993). Guided imagery can be further explained with the effect of endorphins. Relaxation increase endorphins, causing an increase in pain threshold and finally a decrease in pain perception.
Furthermore, the reduction of pain with increase of relaxation, and activation of parasympathetic nervous system resulting in a decrease in blood pressure, respirations and heart rate (Thomas 1991, McCance & Heuther 1998). This method could be problematic as the patient has to be able to focus for at least 20 minutes and to understand the process if he/she wants to implement it. It is important, during guided imagery, to minimise noises and interruptions, to teach the patient to take slow and deep breaths in order to achieve full concentration. Furthermore, exhaustion, sedation or emergency situations affect the patient’s ability to concentrate (Ackerman & Turkoski 2000). Guided imagery is a costless intervention and easy taught it encourages patients’ self-control and reduces the negative effects of medication therapy.
Another, similar to guided imagery, technique is distraction. It is also a self-administered technique that is widely used during venepuncture in children and adolescents. Windich-Biermeier et al. (2007) found that the effect of video games, puzzles or music tables on pain caused during venepuncture was positive. Furthermore, listening to music (live or from a CD player) or watching television reduces the perception of pain (Bellieni et al. 2006, Caprilli et al. 2007). These techniques are also used by dialysis patients without the patient being aware that they are using them. In most Dialysis Units in Greece the patients are encouraged to use their CD or DVD players or watch TV programmes during dialysis. It is a common practice for the Dialysis Unit to have installed television sets in every room, so that patient can spend more pleasantly their time. Unfortunately, these techniques if repeated on a regular basis can become unattractive and can lose their effectiveness.
Relaxation techniques with deep breathing exercises are a very easily taught method, and with no additional equipment cost. Relaxation techniques have a positive effect on anxiety and have proven effective in the management of pain in burn patients (De Jong & Gamel 2006). The patient is less anxious and therefore more relaxed, and the pain perception is diminished.
6.3 MEDICATION THERAPY
Clinicians should have in mind, during the assessment of pain and planning of pain management approaches, the pharmacokinetics and pharmacodynamics of an analgesic agent administered in the presence of Chronic Kidney Disease with reduced or no Glomelural Filtration Rate (Table 2). Both are complex in patients with Chronic Kidney Disease (Davison 2003, Dean 2004, Cohen et al. 2006, Douglas et al. 2009, Tawfic &
Bellingham 2015, Wu et al. 2015). Furthermore, consideration should be given to the effects of analgesic agents in a continuously aging renal population.
6.3.1 Analgesics
By the end of 1980, the World Health Organisation (WHO) identified the absence of national policies on pain relief (Brooksbank 2009) and published the Analgesic Ladder to Treat Pain (WHO 1986) which was revised in 1997. The WHO Analgesic Pain Ladder is the pathway for healthcare professionals in their journey to manage pain. At the beginning the WHO analgesic ladder was addressing only cancer pain, attributing in the realisation of the importance of pain management (WHO 1996, Launay-Vacher et al. 2005, Golan et al. 2009).
It proposed gradual use of analgesics, starting in step one with non-opioid (Aspirin, Acetaminophen, Non-Steroid Anti-Inflammatory drugs) for mild to moderate pain, going to step two to weak opioids (Codeine, Oxycodone) for mild and average pain and continuing to step three with stronger opioids (Morphine, Hydromorphone, Methadone) for average and severe pain combined with other medications, such as tricyclic antidepressants, spasmolytic, antihistaminic, benzodiazepine, corticosteroids. Finally, in step four it is proposed to have nerve block, epidural anaesthesia or patient controlled analgesia (Kurella et al. 2003). The effectiveness of the WHO analgesic ladder has been reported to be 70-80%
(Jadad et al. 1995, Heiwe & Bjuke 2009, Steinberg et al. 2011, Lema 2012).
In the case of renal patients the WHO Analgesic Ladder has been proven to be equally effective (Barakzoy & Moss 2006). Medication selection process should take into account the type and duration of pain, as well as the Renal Replacement Therapy mode (Haemodialysis or Peritoneal Dialysis) that the individual is on. If the chosen pharmacological agent is mostly cleared by non-renal mechanisms, such as the liver, its clearance is not affected by dialysis. The removal of the agent through dialysis depends on its molecular weight, protein binding, volume of distribution, and solubility. More molecules are passing through the dialyser (filter) when the molecular weight is low, whereas the greater the protein binding, the less the molecule is removed. In a similar way, less molecules are removed when the water solubility is high, whereas the greater the volume of distribution, the less molecule is removed per time unit (Dean 2004, Hardy & Reymond 2007). In haemodialysis the removal of molecules is influenced by the dialysate and blood flow rates, the dialysers’ (filter) surface area and capillaries size. The higher the flow rates and the efficiency of the dialyser (high-flux dialyser), the higher is the removal of a medication molecule. In case of peritoneal dialysis, as it has already been mentioned in the second chapter, the dialyser is the patient’s peritoneum, which unfortunately cannot be altered as in haemodialysis. The removal of an agent depends on the permeability of the peritoneum, the volume and consistency of the dialysate and the frequency of the exchanges per day. The more exchanges, the more medication molecules are removed (Dean 2004).
6.3.2 Non-steroidal Anti-inflammatories (NSAIDs)
Non-Steroidal Anti-inflammatories (NSAIDs) are used as first-line agents to control pain in the general population and in renal colics (Holgate & Pollock 2004, Hȍrl 2010), but administration to renal patients should be with caution and should be limited to few days
per time due to renal toxicity, and gastric ulceration. Gastrointestinal bleeding should be a concern due to the fact that most Chronic Kidney Disease stage 5 patients have uraemic platelet dysfunction and are prone to bleeding (Cohen & Davison 2015). Furthermore, if administered, close monitoring of renal function is necessary, as it has been proven to have negative effect on residual kidney function. NSAIDs are not allowed for long-term use and should be avoided (Bajwa et al. 2001, Kurella et al. 2003, Cohen et al. 2006, Plantinga et al.
per time due to renal toxicity, and gastric ulceration. Gastrointestinal bleeding should be a concern due to the fact that most Chronic Kidney Disease stage 5 patients have uraemic platelet dysfunction and are prone to bleeding (Cohen & Davison 2015). Furthermore, if administered, close monitoring of renal function is necessary, as it has been proven to have negative effect on residual kidney function. NSAIDs are not allowed for long-term use and should be avoided (Bajwa et al. 2001, Kurella et al. 2003, Cohen et al. 2006, Plantinga et al.