Non-Pharmacological Interventions for Pain Management in Hemodialysis

Acupuncture demonstrated considerable promise as a benign and efficacious supplementary therapy for managing pain, enhancing functional capacity and muscular strength, lessening symptoms of restless leg syndrome and uremic pruritus, and bettering the QOL of patients on hemodialysis. Additional investigations are imperative to confirm these results and define the ideal parameters for treatment. Cognitive behavioral therapy also exhibited the potential to ameliorate diverse facets of wellness in hemodialysis patients, including social support, QOL, and mental health outcomes. CBT proved successful in attenuating depressive symptom severity, enhancing therapy adherence, and diminishing depression. Internet-based CBT could potentially enhance the accessibility and effectiveness of these interventions for this patient population. Relaxation techniques, encompassing progressive muscle relaxation, guided imagery, deep breathing exercises, and mindfulness meditation, appear to hold potential in managing pain, fatigue, stress, and sleep patterns, as well as in promoting well-being and QOL for hemodialysis patients. Emerging as an innovative immersive technology, virtual reality has demonstrated potential benefits in pain management for individuals undergoing hemodialysis.

pain management
hemodialysis
acupuncture
cognitive behavioral therapy
relaxation techniques
virtual reality

1. Introduction

Hemodialysis is a life-saving treatment for people with end-stage renal disease (ESRD) that involves the removal of toxins and excess fluids from the blood using an artificial kidney. Although hemodialysis is essential to maintain the health of ESRD patients, the process can cause significant pain and discomfort, leading to a lower quality of life [1,2]. Pain faced by hemodialysis patients can be categorized into three categories: (a) procedure-related pain, (b) access-related pain, and (c) pain secondary to renal disease or its complications [3,4]. Effective pain management is crucial during hemodialysis to improve patient compliance, enhance the overall treatment experience, and promote better physical, mental, and emotional well-being [5,6].

3. Acupuncture

Acupuncture is a traditional Chinese medicine technique involving the insertion of thin needles into specific points on the body to stimulate the flow of energy (Qi) and restore balance [11,12,13]. The therapeutic effect is believed to be achieved through the modulation of multiple physiological systems and biochemical pathways, as shown in Figure 2, which describes how acupuncture contributes to pain reduction in ESRD [14,15,16].

Figure 2. The main proposed pathways by which acupuncture interferes with pain intensity.

Several studies have investigated the efficacy of acupuncture for pain management in the hemodialysis group. A recent randomized control trial by Correia et al. [17] in 2022 was conducted on 67 male and female adult patients who presented decreased functional capacity associated with hemodialysis. The study concluded that patients undergoing hemodialysis demonstrated improvements in functional capacity and muscle strength after acupuncture treatment. Similarly, another study was conducted by Bullen et al. [18] on 101 patients with end-stage renal disease, but this time acupuncture was associated with a massage procedure. The conclusion of this study was an improvement in the overall health-related quality of life of the 101 patients, which is confirmed by a new study that revealed that acupuncture was found to enhance the health-related quality of life in individuals undergoing maintenance hemodialysis following their treatment [19]. In addition, a study by Tsai et al. [20] focused on the impact of acupuncture on the reduction of restless leg syndrome (RLS) in hemodialysis patients.

RLS is a common complication that can negatively affect sleep quality and overall well-being. The study revealed that acupuncture treatment significantly decreased RLS symptoms but did not enhance sleep quality in patients on hemodialysis [20]. A systematic review and meta-analysis of seven randomized controlled trials conducted in 2023 showed that acupuncture is a safe and effective treatment for uremic pruritus (UP) in patients undergoing hemodialysis [21].

4. Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy (CBT) is a goal-oriented psychotherapy that focuses on identifying and modifying maladaptive thoughts, emotions, and behaviors [29]. In the context of pain management, CBT aims to help patients develop effective coping strategies, improve pain tolerance, and improve self-efficacy [30]. CBT has been investigated for its potential to treat pain in hemodialysis patients. The systematic review and meta-analysis by Zegarow et al. [31] engaged in an exploration of cognitive behavioral therapy being employed as a psychological treatment strategy. It was reported that the lowering of the intensity of depressive symptoms in patients with hemodialysis. To improve patient well-being, they recommend considering incorporating cognitive behavior therapy as an extension to renal replacement therapy. This was in line with Zheng et al. [27] systematic review and meta-analysis that examined the benefits of CBT on depression and anxiety in hemodialysis patients. Furthermore, a randomized control trial conducted by Valsaraj et al. [32] on 67 chronic kidney diseases found that CBT is more effective than nondirective counseling in improving therapeutic adherence, as well as physiological and clinical parameters among CKD patients undergoing hemodialysis. At six months, the experimental group exhibited a significant reduction in interdialytic weight gain and blood pressure and an increase in adherence to dialysis, fluids, diet, and drugs [32].

5. Relaxation Techniques

Relaxation techniques encompass a variety of non-invasive approaches designed to promote mental and physical relaxation, thus alleviating stress and fostering well-being [37]. Examples of relaxation techniques include progressive muscle relaxation (PMR), guided imagery, deep breathing exercises, and mindfulness meditation [38]. These mechanisms for alleviating discomfort, as depicted in Figure 3, each follow their own unique pathways.

Figure 3. The main pathways by which relaxation techniques modify pain intensity.

Numerous studies have investigated the potential benefits of employing relaxation techniques for pain management in individuals undergoing hemodialysis [39]. A quasi-experimental (time series) study evaluated the effects of increasing muscle relaxation on the intensity of restless leg syndrome (RLS) among adult patients on maintenance hemodialysis [40]. Sixty patients with RLS were divided into two groups, the study group receiving progressive muscle relaxation therapy. Results showed that the severity of RLS significantly decreased in the study group, with improvements observed in sleep patterns, physical activities, emotional well-being, and social activities [40]. A clinical trial, organized under randomized control, explored the impact of directed mental visualization on depressive and anxious symptoms, as well as vital signs, among individuals undergoing hemodialysis [41]. Eighty patients were randomly allocated either to a group undergoing guided intervention or a control group. Results displayed that the guided intervention group endured significantly reduced values of anxiety and depression after the intervention compared to the control group. In addition, there was a reduction in respiratory rate and heart rate in the intervention group [41].

6. Virtual Reality

Virtual reality (VR) is an immersive technology that allows users to experience a computer-generated environment using head-mounted displays and other sensory devices [48]. In the context of pain management, VR has been used as a distraction technique to divert attention away from pain, reducing its perception and emotional impact [49]. While the evidence is still sparse, it holds encouraging potential for employing virtual reality in managing pain for individuals receiving hemodialysis [50,51]. A randomized controlled study evaluated the effects of combining exercise training with VR on functionality and quality of life in patients on hemodialysis [52]. The intervention group showed improved functional capacity and quality of life in physical and specific domains [52]. There was no significant impact on depressive symptoms. Furthermore, a pilot trial study tested the safety, acceptability, and utility of VR during hemodialysis treatment sessions using a new VR program that provided mindfulness training and guided meditation [53]. Patients on hemodialysis (n = 20) experienced the program on two separate occasions, and the results showed significant decreases in treatment and/or motion-related symptoms after VR exposure, with high levels of immersion in the VR environment reported. VR programs may be a safe platform to improve the experience of dialysis patients.

7. Other Alternative Methods

In addition to the previously mentioned NPIs, several alternative methods have been examined to manage pain in hemodialysis patients. These non-pharmacological approaches include transcutaneous electrical nerve stimulation (TENS), music therapy, and aromatherapy. TENS is a non-invasive method that involves delivering mild electrical currents through electrodes placed on the skin to help alleviate pain [56].

In a randomized controlled trial (RCT) conducted by Yang et al. [57], it was observed that TENS significantly reduced pain intensity in hemodialysis patients with access-related pain and increased salivary flow rate [57]. TENS can be a valuable tool in addressing access-related pain in hemodialysis patients. In various contexts, music was demonstrated to have a significant impact on pain reduction [58]. There are several hypotheses regarding the mechanism that underlies the musical effect. By engaging the brain in the processing of musical stimuli, the brain’s capacity to process pain signals may be diminished; this is called the distraction effect [59]. Listening to pleasurable and comforting music can encourage relaxation and positive emotions, which may relieve pain by reducing stress and anxiety; this is called emotional regulation [60]. Lastly, through neurochemical modulation, music induces the release of endorphins, which can act as analgesics to minimize pain sensations [61,62].

Aromatherapy is a type of alternative medicine that employs plant-derived essential oils to promote physical and mental health. While aromatherapy is not a pain remedy, it effectively reduces pain levels and enhances overall comfort [65]. Aromatherapy’s pain-relieving mechanism remains unclear, but multiple hypotheses explain its effectiveness. Aromatherapy activates the limbic system in the brain, which is connected to the olfactory system [66]. This stimulation causes the release of endorphins, a natural painkiller [67]. The delightful aroma of essential oils may distract the mind from painful sensations by acting as a diversion. Lastly, some essential oils possess anti-inflammatory effects, thereby reducing inflammation and relieving pain in afflicted areas [68].

This entry is adapted from the peer-reviewed paper 10.3390/jcm12165390

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