Complementary Therapies for Pain
Among Individuals Receiving
Hemodialysis: A Systematic Review
Savannah Zins
Cynthia R. Gross
Mary Catherine Hooke
ain is a major problem in more
P
than 50% of individuals under-
going hemodialysis (HD), with
many of these individuals
describing ineffective pain manage-
ment (Claxton, Blackhall, Weisbord,
& Holley, 2010; Davison, 2003;
Williams & Manias, 2009). Physical
and psychological strain from pain
can continue for months to years after
beginning HD, impacting quality of
life and ability to perform activities of
daily living (Davison & Jhangri,
2005). In 2015, the United States had
more than 703,000 individuals being
treated for end stage renal disease,
with over 440,000 receiving HD
(United States Renal Data System,
2017). Current methods of pain man-
agement are insufficient for this large
patient population, so it is fundamen-
tal this burden is addressed.
Individuals receiving HD are
among the most symptomatic of any
chronic disease group (Davison,
2007; Kimmel, Emont, Newmann,
Danko, & Moss, 2003; Weisbord et
al., 2005). Inadequate symptom man-
agement in this population is a unique
challenge due to the relationship
between medication distribution and
clearance of bi-products with renal
dysfunction, as well as polypharmacy
in the elderly (Bailie, Mason, Bragg-
Gresham, Gillespie, & Young, 2004;
Savannah Zins, PhD, RN, is Registered Nurse,
Mayo Clinic, Rochester, MN.
Cynthia R. Gross, PhD, is a Professor, Depart-
ment of Experimental and Clinical Pharmacology
and School of Nursing, University of Minnesota,
Minneapolis, MN.
Mary Catherine Hooke, PhD, APRN, PCNS,
CPON, is an Assistant Professor, School of
Nursing, University of Minnesota, Minneapolis,
MN.
Nephrology Nursing Journal January-February 2018
Continuing Nursing
Education
Copyright 2018 American Nephrology Nurses Association.
Zins, S., Gross, C.R., & Hooke, M.C. (2018). Complementary therapies for pain among
individuals receiving hemodialysis: A systematic review. Nephrology Nursing Journal,
45(1), 13-23.
Pain is a major problem for individuals undergoing hemodialysis and can lead to
decreased quality of life when ineffectively managed. Pain is often reported as burden-
some; thus, nurses must learn effective, nonpharmacological adjuncts to help care for
symptomatic patients. The purpose of this review was to identify non-pharmacologic
complementary therapies and evaluate their effectiveness in minimizing pain among
individuals undergoing hemodialysis. Multiple complementary interventions were iden-
tified, and several reduced pain, but evidence is qualified by limitations in study meth-
ods. Complementary therapies have the potential to reduce pain among individuals
undergoing hemodialysis; however, more research is needed.
Key Words: Hemodialysis, pain, complementary therapy.
Davison, 2003). Opioids and other Pain Inventory and McGill Pain
classes of medications are associated Questionnaire are more comprehen-
with undesirable side effects, yet up to sive, addressing intensity, duration,
one-third of individuals with renal dis- and interference with activity
ease use opioids to reduce pain (Hawker, Mian, Kendzerska, &
(Davison, 2003). The etiology of pain French, 2011).
during HD is often multifactorial, and Many patients receiving HD are
it can be acutely HD-related or chron- already using or have expressed a will-
ic. Pain can occur in the context of ingness to use some form of comple-
concurrent symptoms and co-mor- mentary therapy, such as mind-body
bidities, such as fatigue and depression practices like relaxation techniques
or diabetes and vascular disease and body-based methods like massage
(Davison, 2003; Leinau, Murphy, (Akyol, Yildirim, Toker, & Yavuz,
Bradley, & Fried, 2009; Weisbord et 2011; Birdee, Phillips, & Brown, 2013).
al., 2005). Capturing the type of pain There is a growing interest in comple-
and the pain itself has shifted from a mentary therapy among nephrology
linear assessment of bodily pain to patients; however, few studies have
using multidimensional instruments to evaluated strengths and weaknesses of
conduct a comprehensive assessment implementation, as well as effective-
of attributes contributing to total pain ness, of complementary therapies in
perception. For example, an analog dialysis clinics and among the popula-
scale is useful for assessing a global tion (Nowack & Birck, 2012). Comple-
perception of pain, whereas the Brief mentary therapies offer additional
Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this
continuing nursing education activity.
Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can
be found on page 24.
Vol. 45, No. 1 13
Complementary Therapies for Pain Among Individuals Receiving Hemodialysis: A Systematic Review

Figure 1
PRISMA Flow Diagram of Identification and Selection of Articles

Records identified through Additional records

database searching identified
(n=809) (n=2)

Records after duplicates removed

(n=686) Reasons for exclusion of
title and abstract:
1. Herbal or pharmacological
trial
Records screened Records excluded 2. Treating animals
(n=686) (n=538) 3. Case report
4. Not in English

Full-text articles Full-text articles

assessed for eligibility excluded
(n=148) (n=140)

Reasons for exclusion of articles:

Studies included in 1. No pain statistics reported
quantitative review 2. Not a randomized controlled
(n=8) trial or quasi-experimental

Source: Moher, Liberati, Tetzlaff, & Altman, 2009.

treatment options to improve the pain
experience and quality of life for indi-
viduals receiving HD. The aim of this
systematic review is to evaluate the
evidence for the effectiveness of non-
pharmacologic, complementary ther-
apies on pain among individuals
undergoing HD.
Methods
Databases and Search Terms
A systematic search was conducted
in three databases, including using the
ancestry approach to find additional
studies. To locate intervention studies
examining non-pharmacologic com-
plementary therapy use to minimize
pain among individuals receiving HD,
the following databases were searched:
OVID Medline, Embase, and
CINAHL. Subject headings included
“hemodialysis” OR “renal dialysis,”
AND “complementary therapies.”
The subject heading “pain” was not
used in order to identify papers that
may have included pain as a second-
ary outcome. The search resulted in a
total of 811 citations. After removing
duplicates, 686 papers were reviewed
by title and abstract.
Inclusion Criteria
Studies retained for review were
articles that reported results of non-
pharmacologic and non-herbal inter-
vention research, included patients
receiving HD, used a randomized
controlled trial (RCT) or comparative
quasi-experimental design, had pain
as a primary or secondary outcome,
and were published in English. If stud-
ies used multi-symptom instruments,
pain subscale results had to be includ-
ed. These studies were reviewed for
quality by examining design, interven-
tions, pain measures, strengths, and
limitations. After reviewing titles and
abstracts to exclude articles using
herbal therapies, animals, case
reports, and those not in English, 148
remained. Herbal therapies were
excluded because we were examining
non-pharmacologic complementary
therapies. After applying all inclusion
criteria on the remaining full-text arti-
cles, 8 articles were identified as rele-
vant and were included in this review
(see Figure 1).
Results
The eight studies chosen for review
were published between 2007-2014.
One article was published in 2007,

14 Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1

2008, 2010, 2013, and four were pub-
lished in 2014. Studies included seven
RCTs and one quasi-experimental
design. All studies reviewed were 2-
group designs. One study had placebo
comparators, one study assigned
active range-of-motion exercises to
both groups, and the remaining studies
had usual care controls. Four studies
measured pain pre- and post-interven-
tion, while four studies measured pain
at baseline and again at the end of the
study period. The study that used a
numeric rating pain scale lacked detail
on whether participants were asked to
recall pain over a period of time or
were to report pain in the moment.
Most studies did not measure co-mor-
bidities (n=7) or concurrent symptoms
(n=4).
All eight studies were conducted in
Mediterranean countries (n=4) or Iran
(n=4). Characteristics of the eight stud-
ies are shown in Table 1. Sample sizes
of seven studies ranged from 40 to 114
participants. Sex and age were report-
ed by all studies. Mean age ranged
from 38 to 68 years in the seven stud-
ies of adults, and one study included a
group of adolescents with a mean age
of 14 years. Most participants were
male, with percentages of males rang-
ing from 37.5% to 70%; two studies had
more females (Burrai, Micheluzzi,
Zito, Pietro, & Sisti, 2014; Ozdemir,
Ovayolu, & Ovayolu, 2013). Two stud-
ies did not report education data
(Pothoulaki et al., 2008; Yurtkuran,
Alp, Yurtkuran, & Dilek, 2007). One
study reported religion (Burrai et al.,
2014). Four studies reported mean
duration of HD, ranging from 1 to 5
years for participants (Alhani, Shad,
Anoosheh, & Hajizadeh, 2010;
Ozdemir et al., 2013; Rambod, Sharif,
Pourali-Mohammadi, Pasyar, & Rafii,
2014; Yurtkuran et al., 2007).
The eight studies reviewed includ-
ed the following as pain interven-
tions: Hatha yoga, distraction, reflex-
ology, aromatherapy, Benson’s relax-
ation method, and music. Only one
study mentioned being guided by a
theory about pain (Alhani et al.,
2010); none included a theory relating
the intervention to pain. Yoga was the
only group intervention. The remain-
ing interventions were all provided
on an individual level. In two studies,
the interventionist was a researcher
(Pothoulaki et al., 2008; Ozdemir et
al., 2013), one intervention was deliv-
ered by a certified yoga teacher
(Yurtkuran et al., 2007), and another
was delivered by a holistic nurse
(Burrai et al., 2014). Interventionist
training was described in two studies
(Ozdemir et al., 2013; Yurtkuran et
al., 2007). Four studies did not
describe the interventionist.
Two trials were conducted in HD
units and were designed to reduce
venipuncture pain. Alhani and col-
leagues (2010) aimed to determine the
effect of programmed distraction on
pain caused by venipuncture in ado-
lescents and reported significant differ-
ences between groups and within the
intervention group. The intervention
was investigated over 12 HD sessions,
and pain intensity was measured using
the Wong-Baker FACES pain scale.
This study lacked power calculations,
random assignment, and blinding, and
did not report any dropouts. Bagheri-
Nesami, Espahbodi, Nikkhah, Shorofi,
and Charati (2014) aimed to determine
the effects of lavender aromatherapy
on pain caused by venipuncture in
adults and reported significant differ-
ences between mean pain severity
score between groups after thre inter-
ventions. The intervention was investi-
gated over three consecutive HD ses-
sions, and pain intensity was measured
using a visual analog scale (VAS). This
study provided power calculations and
appropriately described attrition,
accounted for pain medications given
to participants, and used a placebo
aromatherapy group as the control.
Both studies were unable to assign one
individual to perform all venipunc-
tures.
Two trials designed to investigate
the effects of music on pain were con-
ducted during HD. Pothoulaki et al.
(2008) aimed to determine the effects
of preferred music listening via com-
pact discs on anxiety and pain per-
ception. These researchers reported
no significant difference between
groups in pain intensity, but a signifi-
cant increase in pain intensity in the
control group, as well as a significant,
positive correlation between pain
intensity and state anxiety scores,
indicating a relationship between
symptom experiences. The interven-
tion was investigated over one HD
session, and pain intensity was meas-
ured using a VAS and the McGill
Pain Questionnaire. This study lacked
a power calculation. Burrai and col-
leagues (2014) aimed to determine the
effects of live saxophone music on
various physiological parameters and
on pain, mood, and itching levels,
and reported a significant difference
in pain within the music group and
between the two groups. The inter-
vention was investigated one time per
week over four weeks and took place
in an HD unit. Acute pain intensity
was measured using a VAS, and a
power calculation was provided. Both
studies lacked blinding, did not report
any dropouts, and measured pain
related to HD.
Two trials designed to evaluate the
effect of Benson’s relaxation technique
were conducted in the HD unit and
continued at home. Rambod and col-
leagues (2014) aimed to determine the
effects of Benson’s relaxation tech-
nique on relieving pain and improv-
ing quality of life, and reported a sig-
nificant difference in mean pain scores
between groups. The intervention was
conducted over eight weeks, and pain
intensity was measured by a numeric
pain scale at baseline and again at the
end of eight weeks. The numeric pain
scale had a test-retest reliability of
r=0.94. Intervention adherence meas-
ures were reported. The relaxation
technique was performed a mean of
11.34 (SD=2.55) times per week out of
14, and for a mean duration of 34.5
minutes (SD=5.32) out of 40.0 min-
utes per day. The study did not meas-
ure anxiety or stress to assess if partic-
ipants could relax during the interven-
tion. Heidari Gorji, Abbaskhani
Davanloo, and Heidarigorji (2014)
aimed to determine the impact of
Benson’s relaxation method on stress,
anxiety, and pain perception, and
reported a significant difference in
pain between groups. The study also
found significant correlations between

Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 15

 16
Table 1
Reviewed Studies of Complementary Therapies for the Treatment of Pain

Reference and Pain Pain + Strengths and

Country Purpose Design Sample/Setting Intervention Measures Outcomes - Limitations
Yurtkuran et al. Evaluate the Randomized N=37: intervention Modified Hatha VAS Significant improve- - Classes at HD
(2007) effects of a yoga- controlled trial. (n=19), control yoga: 30 minutes ments in pain inten- center, but
Country: Turkey based exercise (n=18) per day, twice a sity between groups lacked detail if
program on pain, Convenience week for 3 (p<0.05). participants
fatigue, sleep sampling months. 37% change in pain completed yoga
disturbance, and Gradually intensity in before or after
biochemical Sex: males (n=16), increased over HD sessions.
females (n=21) intervention group.
markers in time from 15 - No report of
patients on HD. Mean age: 38 years minutes to goal comorbidities or
(SD=14.2) of 30 minutes. HD duration.
intervention, 41 Active ROM
(SD=9.97) control - No power
exercises at analysis.
No significant group home daily for
differences ten minutes for - No theory.
both groups.
Interventionist:
certified yoga
teacher.

Pothoulaki et al. Evaluate the Randomized N=60: Intervention Experimental VAS No significant - A third of
(2008) effects of controlled trial. (n=30), control group listened to difference between participants did
Country: Greece preferred music (n=30) preferred music groups in pain not have any
listening on Convenience provided during intensity. pain at
anxiety and pain sampling HD via CD No significant within- baseline.
perception player. group differences in - Sample
among patients Sex: males (n=42),
females (n= 18) Control group pain intensity scores included
undergoing HD.

Nephrology Nursing Journal

had standard for intervention patients on both
Mean age: 52.9 care. group. inpatient and
years outpatient HD.
Interventionist: Significant increase
Complementary Therapies for Pain Among Individuals Receiving Hemodialysis: A Systematic Review

No significant group researcher. in pain intensity - No inclusion

differences post-intervention for criteria, report
control group of
(p<0.001). comorbidities,
Positive, significant or HD duration.
correlation between - No power

January-February 2018
pain intensity and analysis.
state anxiety scores - No theory.
(p<0.01).

continued on next page

Vol. 45, No. 1

 Table 1 (continued)
Reviewed Studies of Complementary Therapies for the Treatment of Pain

Reference and Pain Pain + Strengths and

Country Purpose Design Sample/Setting Intervention Measures Outcomes - Limitations
Alhani, Shad, Evaluate the Quasi- N=42: intervention Content: 2 McGill Pain Significant difference - Three
Anoosheh, & effect of experimental (n=21; 1 HD center), pictures for Questionnaire within intervention individuals did
Hajizadeb (2010) programmed design control (n=21; 2 HD adolescents to group and between venipunctures.
Country: Iran distraction on centers) identify groups. - No report of

Nephrology Nursing Journal

pain caused by Convenience differences No change in pain comorbidities.
venipuncture sampling during after five sessions,
among venipuncture - No power
Sex: males (n=25), but significant analysis.
adolescents on over 12 HD decrease in pain at
HD. females (n= 17) sessions. - Theory provided
sixth HD session.
Mean age: 13.86 Different pictures for pain, not
years (SD=3.19) each HD session. intervention.
intervention, 14.81
years (SD=3.51) Control group
control had standard

January-February 2018
care.
No significant group
diferences Interventionist:
unidentified.

Ozdemir, Evaluate the Randomized N=80: intervention Reflexology for Wong-Baker Significant difference - No report of
Ovayolu, & effect of foot controlled trial (n=40), control 1 week across 3 FACES Pain in pain was found comorbidities.

Vol. 45, No. 1

Ovayolu (2013) reflexology on (n=40) HD sessions; Rating Scale within and between - No power
Country: Turkey fatigue, pain and Convenience each session groups (p<0.05). analysis.
cramps in sampling lasting 30 In both groups,
patients on HD. minutes after HD - No theory.
Sex: males (n=30), women experienced
session. more fatigue, pain
females (n=50)
15 minutes per and cramp more
Mean age: 43.1 foot: 7 minutes of intensively compared
years (SD=15.8) reflexology, 5 with men (p<0.05).
intervention, 54 minutes before,
years (SD=12.8) Patients with lower
and 3 minutes hematocrit, albumin,
control after of relaxation and Kt/V levels
No significant group technique. experienced more
differences Control group pain.
had standard
care.
Interventionist:
certified
reflexologist.

continued on next page

17
 18
Table 1 (continued)
Reviewed Studies of Complementary Therapies for the Treatment of Pain

Reference and Pain Pain + Strengths and

Country Purpose Design Sample/Setting Intervention Measures Outcomes - Limitations
Bagheri-Nesami Evaluate the Randomized N=92: intervention Intervention VAS No significant - Unable to
et al. (2014) effects of controlled trial (n=46), placebo group inhaled differences between assign
Country: Iran lavender (n=46), with 4 lavender essence mean pain severity consistent
aromatherapy on dropouts with score between the 2 nursing staff for
pain following Convenience concentration of groups, but all needle
needle insertion sampling 10% for 5 significant difference insertions.
into a fistula. minutes during 3 between groups in - No report of
Sex: males (n=52), consecutive HD mean pain severity
females (n=40) comorbidities.
sessions. after 3 interventions
Mean age: 60.95 (p=0.009). - No theory.
Control group
years (SD=1.93) inhaled Significant + Provided power
intervention, 58.06 aromatherapy differences within analysis.
years (SD=1.83) free of lavender intervention group of
control essence. mean pain severity
No significant group Lavender and before and after 3
differences placebo both interventions
diluted with (p=0.0001).
sweet almond oil. Patients receiving 3
Interventionist: placebo therapies
unidentified. experienced less
pain than they did
before the
intervention
(p=0.0001).

Burrai et al. Evaluate the Randomized N=114: intervention Intervention VAS A significant differ- - Lacked detail if

Nephrology Nursing Journal

(2014) effects of live controlled trial (n=57), control group received ence in pain was saxophone
Country: Italy saxophone music (n=57) 30 minutes of found within the music was
on various Convenience individualized music group and played before,
Complementary Therapies for Pain Among Individuals Receiving Hemodialysis: A Systematic Review

physiological sampling selection of live between the 2 during, or after

parameters and saxophone music groups (p<0.05). HD sessions.
on pain, mood Sex: males (n= 49), weekly for 4
females (n= 65) - No report of
and itching levels weeks. comorbidities.
in patients Mean age: 68.2 Control group
undergoing HD. years (SD=11.7) - No theory.
had standard
+ Provided power

January-February 2018
No significant group care.
differences analysis.
Interventionist:
holistic nurse.

continued on next page

Vol. 45, No. 1

 Table 1 (continued)
Reviewed Studies of Complementary Therapies for the Treatment of Pain

Reference and Pain Pain + Strengths and

Country Purpose Design Sample/Setting Intervention Measures Outcomes - Limitations
Heidari Gorji, Evaluate the Randomized N=80: intervention Intervention McGill Pain A significant - Lacked detail if
Abbaskhani, impact of controlled trial (n=40), control group watched Questionnaire difference in pain video was
Davanloo, & Benson’s (n=40) video to learn – Short Form. was found between played before,
Heidarigorji relaxation Convenience Benson groups (p<0.001). during, or after

Nephrology Nursing Journal

(2014) method on sampling relaxation A correlation HD sessions.
Country: Iran stress, anxiety, method, as well between pain and - Excluded
and pain Sex: males (n=44), as caregiver, in
females (n=36) stress (r=0.563), anyone with a
perception of the HD center. anxiety and pain co-morbidity
patients. Mean age: 48 years Technique (r=0.489), and age except diabetes
(SD=12.53) performed twice and pain (r=0.268) and
a day for 15 was found (p<0.000). hypertension.
No significant group minutes for 4
differences weeks. - No theory.
+ Provided

January-February 2018
Control group
had standard reliability and
care. validity for
measures.
Interventionist:
unidentified. + Provided power
analysis.

Vol. 45, No. 1

Rambod et al. Evaluate the Randomized N=86: intervention Intervention Pain numeric A significant - Participants
(2014) effects of controlled trial (n=41), control group listened to rating scale difference in mean with physical
Country: Iran Benson’s (n=40), with 5 audiotape of pain scores between limitations were
relaxation dropouts technique twice a groups (p=0.01). excluded from
technique in Convenience day for 20 Mean score of pain the study.
relieving pain and sampling minutes each intensity had - Anxiety and
improving quality time for 8 weeks. significantly stress not
of life in patients Sex: males (n=53),
females (n=33) Control group decreased within measured.
on HD. had standard intervention group.
Mean age: 49.07 - No report of
care. co-morbidities.
years (SD=13.31)
intervention, 50.72 Interventionist: - No theory.
years (SD=11.68) unidentified.
+ Provided
control reliability and
No significant group validity for
differences measures.
+ Provided power
analysis.

Notes: HD = hemodialysis, ROM = range of motiion, VAS = visual analog scale.

19
Complementary Therapies for Pain Among Individuals Receiving Hemodialysis: A Systematic Review
pain and stress, as well as between
pain and anxiety. The intervention
was investigated over four weeks, and
pain severity was measured by the
McGill Pain Questionnaire Short
Form, with an internal consistency of
0.84 pre- and post-intervention. The
study lacked detail on intervention
adherence. Both studies provided
power calculations and appropriately
described attrition, had partial blind-
ing of data collectors and intervention-
ists, provided pain measure psycho-
metric results, and measured chronic
pain.
The remaining two trials were
designed to reduce pain using Hatha
yoga or foot reflexology for individu-
als receiving HD. Yurtkuran and col-
leagues (2007) aimed to determine
the effects of a yoga-based exercise
program on pain, fatigue, sleep distur-
bance, and biochemical markers, and
reported significant improvements in
pain intensity between groups and a
37% change in pain intensity in the
intervention group. The intervention
was delivered twice per week over
three months, and pain intensity was
measured using a VAS at baseline
and upon completion of the study.
The study lacked detail on the timing
of yoga sessions in relation to HD ses-
sions, lacked detail on adherence
(average number of yoga sessions
attended), lacked a power calculation,
had partial blinding of physician
examining patients, and appropriate-
ly described attrition. Ozdemir and
colleagues (2013) aimed to determine
the effect of foot reflexology on
fatigue, pain, and cramps, and report-
ed a significant difference in pain
within and between groups. They
also found that participants with
lower Kt/V and albumin had signifi-
cantly more pain and that women
experienced more pain and fatigue.
The intervention was delivered after
three HD sessions, and pain severity
was measured using a VAS at base-
line and upon study completion. The
study mentioned a power calculation
without adequate detail, lacked blind-
ing, and did not report any dropouts.
Both studies lacked detail on recall
duration and type of pain measured.
20
Discussion
The aim of this review was to eval-
uate the evidence from controlled tri-
als on the effectiveness of complemen-
tary therapies as a treatment for pain
in individuals undergoing HD.
Evidence of the effectiveness of com-
plementary therapies for pain in
patients on HD was found, but study
limitations qualify the findings. Most
studies used only one pain measure
and did not report concurrent symp-
toms or co-morbidities. Only one
study was conducted by a nurse inves-
tigator or had a nurse as the interven-
tionist. This discussion will highlight
the methodology, pain measures,
strengths, and limitations of studies
reviewed.
Sample sizes were small or rela-
tively modest; only one study includ-
ed over 100 participants. No large
imbalances or significant differences
in baseline characteristics between
intervention and control groups were
found, supporting internal validity.
The study by Pothoulaki and col-
leagues (2008) was the only reviewed
study lacking a detailed power calcu-
lation and reporting a nonsignificant
difference in pain between groups. Of
the seven studies with significant out-
comes, all reported some form of
recurring contact with intervention
group participants, possibly indicat-
ing that individual attention and
social support are important in pro-
moting treatment effects. Protocol
integrity of the intervention and clini-
cal effectiveness of HD sessions was
not described in any study, and thus
treatment fidelity cannot be con-
firmed. Both studies reporting inter-
ventions specifically for venipuncture
were unable to control for venipunc-
turist technique because there was no
uniform staff to perform the proce-
dure. This confounding variable
could impact reports of pain if partic-
ipants had a previous relationship,
good or bad, with the venipuncturist,
or if they used differing techniques,
yet both studies reported significant
findings. More detail on individual
treatment protocols and consistent
reporting of adherence (“dose”)
Nephrology Nursing Journal
received by participants would
enhance validity and reproducibility.
One reviewed study provided indi-
vidualized reflexology based on pain
reported but did not adequately
describe different protocols for each
participant at each reflexology session
(Ozdemir et al., 2013). Given the
holistic and individualized nature of
many complementary therapies, a
thorough protocol needs to be devel-
oped and followed to provide a stan-
dard or manual for study replication
by others to establish effectiveness for
individualized treatments.
Seven reviewed studies reported
the intervention was performed on
HD days. Both interventions before
venipuncture supported favorable
outcomes; however, timing patterns
over the other reviewed studies did
not appear to predict favorable out-
comes. Delivering interventions in
coordination with HD sessions can
increase intervention consistency and
adherence for the HD population.
Accounting for nursing workflow and
resource management is important
when attempting to implement inter-
ventions during scheduled HD
appointments to reduce burden on
staff, clinical flow, and cost of delays,
as well as reduce participant burden
and possibly increase intervention
compliance. One study was conduct-
ed after HD sessions (Ozdemir et al.,
2013), which could have an impact on
nursing workflow and cost because it
could cause schedule and transporta-
tion delays for patients.
Only one study reported a con-
ceptual theory, specifically the Gate
Control Theory of Pain (Alhani et al.,
2010). A theoretical approach could
improve the intervention and study
design to enhance the quality of find-
ings. The complex nature of symp-
toms and standard treatments for
individuals receiving HD could bene-
fit from a theoretical framework
based on the complementary therapy
being studied (Lewith, Walach, &
Jonas, 2012). Many complementary
therapies, such as mind-body thera-
pies, are based on interconnectedness
and individuality; thus, the challenge
for researchers is to connect philo-
January-February 2018 Vol. 45, No. 1
sophical values of complementary
therapies with rigorous standards of
research design and implementation.
Using a theoretical framework can
help navigate challenges of construct-
ing uniform experimental conditions
while remaining true to the holistic
basis of many complementary thera-
pies.
Different types of pain are report-
ed by individuals receiving HD,
including HD-related pain and
chronic pain. Assessing not only the
pain itself, but the type of pain, can
help tailor interventions appropriate-
ly. Several studies included in this
review lacked detail on the type of
pain being measured, as well as the
recall period participants self-report-
ed. The type of pain to be treated
could impact the choice of interven-
tion and its effectiveness, as well as
guide the selection of the appropriate
pain measurement tool.
Fatigue, intradialytic hypotension,
cramps, and dizziness, as well as
headache, pruritus, and backache are
common during HD sessions (Caplin,
Kumar, & Davenport, 2011; Gamondi
et al., 2013). In addition to these treat-
ment-related pains, chronic pain from
co-morbidities, including muscu-
loskeletal pain, neuropathies, and
peripheral vascular pain, are common
for individuals on HD (Davison,
2003; Murtagh, Addington-Hall, &
Higginson, 2007). Pain is multidimen-
sional and often chronic among indi-
viduals undergoing HD; therefore, it
can continue beyond HD sessions.
Other physical and psychological
symptoms are also known to be multi-
factorial and of high burden (Patel,
2013). The presence of disease bur-
den, co-morbidities, and concurrent
symptoms may impact the perception
of pain and the effectiveness of select-
ed interventions. Findings from this
review are inconsistent on this topic.
Rambod and colleagues. (2014) did
not measure stress or anxiety to deter-
mine if participants relaxed after
Benson’s relaxation technique, which
could impact pain reports of partici-
pants and overall study findings.
Pothoulaki and colleagues (2008)
measured pain intensity and anxiety,
and found a positive, significant corre-
lation (p<0.01), while Ozdemir and
colleagues (2013) found no relation-
ship between the mean pain and
fatigue scores or other physiological
factors. None of the reviewed studies
reported co-morbidities, and most did
not measure or compare concurrent
symptoms. Chronic pain may con-
tribute to symptoms of anxiety and
physiological imbalances; thus, such
symptoms may also lower pain
thresholds. Davison (2003) found 83%
of patients on HD experienced mod-
erate or severe pain in the previous 24
hours. Distressing symptoms, such as
depression, also often co-exist in this
population (Davison & Jhangri, 2005).
This emphasizes chronic pain as a fun-
damental concern among individuals
receiving HD, and is often associated
with psychosocial distress and burden
(Davison, 2007). Assessing and
addressing psychosocial burdens and
co-morbidities, may decrease the
impact of pain among the HD popu-
lation, thus improving overall quality
of life (Patel, 2013).
Four different pain measures were
used, with the VAS used most often.
Variety in timing of pain measures
make it difficult to directly compare
results across the studies reviewed.
Lack of consistency in timing could
reflect the lack of a theory-based study
for intervention selection and inade-
quate consideration of the physiologic
impacts of HD. For example, many
studies measured pain pre- and post-
intervention, while others measured
pain at baseline and at the end of the
study. Pain is associated with psychoso-
cial factors; thus, the assessment of pain
has progressed from a single measure-
ment of physical pain to a comprehen-
sive measurement of attributes con-
tributing to the perception of pain
(Breivik et al., 2008). To assess all com-
ponents, comprehensive pain tools that
capture the multidimensional nature of
pain should be used. Such tools have
been suggested for the HD population,
including the Brief Pain Inventory,
McGill Pain Questionnaire, Pain
Management Index, and Edmonton
Symptom Assessment System, but
none are consistently used (Upadhyay,
Cameron, Murphy, & Battistella, 2014).
Two reviewed studies measured pain
using the McGill Pain Questionnaire,
and five used the VAS. Only one study
used both the McGill Pain Ques-
tionnaire and a VAS to capture global
pain (Pothoulaki et al., 2008). Using a
multidimensional method of measur-
ing pain in addition to a VAS can be
more effective for examining the clini-
cal importance of pain and emotional
functioning as a research outcome
(Dworkin et al., 2008). Quality of life is
important for the HD population.
Thus, the perception of symptom bur-
den could provide a more complete
picture of how the patient feels than
pain experienced or measured alone.
Current methods of symptom
management may contribute to
under-treatment of symptoms or
over-sedation and other unfavorable
side effects. Complementary thera-
pies often focus on minimizing how
bothersome symptoms are and
improving physical and emotional
well-being rather than curing. Several
studies report a wide range of com-
plementary therapies uses prevalence
among individuals undergoing HD
(Akyol et al., 2011; Birdee et al.,
2013). A study surveying 89 individu-
als receiving HD found 61% of indi-
viduals reported using complementa-
ry therapy at some point in their life-
time. Mind-body interventions were
the most popular, and the highest
rates of use were among individuals
aged 50 to 64 years and women
(Birdee et al., 2013). In another study,
25% of 206 individuals receiving HD
reported the use of one complemen-
tary therapy or more. The highest
rates of use were among women and
individuals aged 51 to 70 years. Mind-
body interventions were the most
popular, used by 46% of participants
(Akyol et al., 2011). As Ozdemir and
colleagues (2013) found women expe-
rienced pain, fatigue, and cramping
more intensively than men, and
Heidari Gorji and colleagues (2014)
found age and pain are correlated. It
is plausible that women and older
adults could be more symptomatic,
and thus, willing to try complementa-
ry therapies.

Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 21

Complementary Therapies for Pain Among Individuals Receiving Hemodialysis: A Systematic Review
Indications for Future Research
The prominent finding of this sys-
tematic review was that several com-
plementary therapies show promise as
adjunct therapies for pain reduction in
patients receiving HD. Although most
studies reviewed were RCTs, the diver-
sity of complementary therapy
approaches, lack of replication, and
methodological shortcomings limit the
generalizability of findings. None of
the studies reviewed were longitudi-
nal; thus, there was no information on
the durability of pain reductions,
which is particularly important for
chronic pain. Relationships among co-
morbidities and symptoms were large-
ly unexamined. Moreover, many
other complementary therapy modali-
ties have the potential to reduce pain
symptoms but have not been tested in
the HD population. Individuals receiv-
ing HD need more therapeutic options
for pain, and these patients may be
interested in complementary thera-
pies; however, research to unlock the
potential of complementary therapy
interventions to reduce pain and
improve outcomes for patients on HD
has received scant attention. Future
research in which replication with fully
powered RCT studies using multidi-
mensional pain measures may better
determine the value and generalizabil-
ity of interventions for this population,
as well as safety and efficacy. Using a
theory base to help lead methodologi-
cal design for complementary thera-
pies could lead to more significant and
generalizable findings for pain control.
Implications for Practice
Findings of this review support the
potential of complementary therapies
as an adjunct for pain management
among individuals receiving HD.
Some therapies may be less feasible
due to lack of experienced interven-
tionist or the potential time and cost
involved. However, promising results
emerging from Mediterranean coun-
tries and Iran could provide evidence
for other Western settings to accept
these therapies and increase accessi-
22
bility. There is a need to implement
effective therapies to reduce pain, and
incorporating them into already
scheduled HD sessions may prove
beneficial to patients and the multidis-
ciplinary team. Opportunities exist for
nurses to adopt approaches and make
complementary therapies more con-
venient and acceptable to patients.
Conclusion
In conclusion, there could be a
role for complementary therapies to
contribute to improving pain man-
agement among individuals undergo-
ing HD. Although promising results
were found, the overall evidence is
not sufficiently robust to recommend
specific interventions as safe and
effective for pain management in the
HD population. An important role of
nurses is to find ways to alleviate
symptoms of HD. Complementary
therapies show potential for reducing
pain, but they require acceptance
among the traditional Western health-
care model, as well as expertise to
ensure accuracy and safety of inter-
vention modality. More RCTs to
explore options for reducing pain that
are acceptable to patients receiving
HD are needed. With a high level of
interest in complementary therapies,
additional research is needed in the
United States and Canada to further
advance our knowledge of the bene-
fits of integrative therapies in the HD
population.
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Vol. 45, No. 1 23
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