Original Article

Management of Pain and

Quality of Life in Patients
with Chronic Kidney
Disease Undergoing
Hemodialysis
---

From the *Department of Nursing,

Faculty of Human Movement and
Quality of Life Sciences, University of
Peloponnese, Sparta, Lakonia,
Greece; General Hospital of Thoracic
Diseases, Athens, Attiki, Greece.
Address correspondence to Victoria
Alikari, RN, MSc, PhD(c), Department
of Nursing, Faculty of Human
Movement and Quality of Life
Sciences, University of Peloponnese,
Efstathiou & Starmatikis Valioti &.,
23100 Sparta, Lakonia, Greece.
E-mail: vicalikari@gmail.com
Received March 15, 2015;
Accepted March 17, 2015.
1524-9042/$36.00

2015 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2015.03.004

Sofia Zyga, PhD,* Victoria Alikari, RN, MSc, PhD(c),*

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

ABSTRACT:

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

2015 by the American Society for Pain Management Nursing

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

Zyga et al.

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

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

2005; Shayamsunder, Patel, Jain, Peterson, & Kimmel,

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

Pain and Quality of Life in Hemodialysis

Multiphasic Personality Inventory-2 (MMPI-2) is the

most frequently used assessment tool for evaluating
the characteristics of the personality in patients
suffering from chronic pain (Arbisi & Butcher, 2004).

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

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

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

Zyga et al.

the PSEQ was used to examine patient-reported

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

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

TABLE 1.
Participant Demographics
Demographic Data

Frequency

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

Percentage

101
123

45.1
54.9

27
94
78
25

12.1
42.0
34.8
11.2

142
39
19
24

63.4
17.4
8.5
10.7

57
31
74
33
29

25.4
13.8
33.0
14.7
12.9

102
76
46

45.5
33.9
20.5

22
32
20
108
42

9.8
14.3
8.9
48.2
18.8

34
28
15
3
144

15.2
12.5
6.7
1.3
64.3

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

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

Mean

SD

Minimum Maximum

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

3.0
5.7
11.5

7.45
10.92
11.28

16.0

30.0

30.0

30.0
30.0
30.0

7.3

8.9

9.81
11.61

30.0

30.0

30.0
30.0

Pain and Quality of Life in Hemodialysis

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

Frequency

Percentage

9
20
98
87
10

4.0
8.9
43.8
38.8
4.5

coefficient r was calculated. Findings suggested a statistically significant correlation between overall QoL
and self-efficacy in pain. Specifically, the more effective
the self-efficacy in pain, the lower QoL of patients as
regards the overall QoL for patients with CKD
(r
0.315, p value < .001).
Gender affects neither self-efficacy in pain
[t(222) 0.667, p .506] nor QoL [t(222)
0.794,
p < .428]. Age affects self-efficacy in pain [KruskalWallis c2(3) 37.214, p < .001] and QoL [KruskalWallis c2(3) 20.746, p < .001]: The greater the age
of patients, the less self-efficacy in pain. Conversely,
younger patients (2140 years old) had lower quality
of life (mean
13.3) compared with older patients
(6180 years old) (mean 13.4).
Self-efficacy in pain is affected by mobility problems [t(222) 9.708, p < .001], hypertension
[t(222) 4.786, p < .001], heart disease
[t(222) 6.158, p < .001], and bone disease
[t(222) 6.158, p < .001], as well as cramps
[t(222) 3.358, p .001], headache [t(222) 4.965,
p < .001], and itchiness [t(128.182) 5.154,
p < .001] during the HD session. Patients who had
mobility problems (mean 18.7); suffered from hypertension (mean 29.1), heart disease (mean 27.6),
and bone disease (mean 21.9); or experienced
cramps (mean 30.0), headaches (mean 28.4) and
itchiness (mean 25.6) during the HD session seemed
to manage pain in a less-effective way.
Self-efficacy in pain was also affected by marital
status [Kruskal-Wallis c2(3) 34.419, p < .001],

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

Mean

SD

Minimum

Maximum

PSEQ

32.5

14.43

60

SD standard deviation.

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

Correlation Coefficient r

p Value

PSEQ MVQOLI

0.315

<.001*

*Statistically significant outcome at a significance level of 1%.

number of children [Kruskal-Wallis c2(4) 37.645,

p < .001], educational level [F (2,221) 24.889,
p < .001], and employment status [Kruskal-Wallis
c2(4) 32.307, p < .001]. Widowers (mean 23.5),
patients with four children (mean 21.1), patients
with less than a high school education (mean
25.9), retired patients (mean 29.2), and patients
having to manage domestic tasks (mean 27.7)
seemed to manage pain in a less effective way.
Marital status affected symptoms [Kruskal-Wallis
c2(3) 8.502, p .037] and spirituality [KruskalWallis c2(3) 14.939, p .002]. Number of children
affected functionality [Kruskal-Wallis c2(4)- 13.071,
p .011] and spirituality [Kruskal-Wallis
c2(4) 9.918, p .042]. Educational level affected
functionality [F(2,221) 5.443, p .005], wellness
[F(2,221) 4.088, p .018], and spirituality
[F(2,221) 6.653, p .002]. Finally, employment status
affected functionality [Kruskal-Wallis c2(4) 32.543,
p < .001], wellness [Kruskal-Wallis c2(4) 10.007,
p .040], and spirituality [Kruskal-Wallis
c2(4) 13.687, p .008]. None of the demographic
characteristics affected the dimension interpersonal
relationships.
As far as the dimension symptoms of QoL is concerned, our findings showed that widowers
(mean 0.5) experienced lower QoL than the others.
For functionality, patients having 2 children
(mean 2.9), patients with secondary education
(mean 3.1), and unemployed patients (mean

3.2) had a lower QoL than the others. Patients
with secondary education (mean
9.8) and patients
with a part-time job (mean
12.4) had the lowest QoL
scores under wellness. Regarding the dimension spirituality, divorced (mean
13.8) and unmarried
(mean
13.5) patients, patients having zero
(mean
12.8) or one (mean
10.8) child, patients
with secondary (mean
11.8) and higher
(mean
10.7) educations, and patients with parttime jobs (mean:
14.6) fared the worst.
Diabetes affected symptoms [t(222) 4.368,
p < .001], and patients suffering from diabetes
(mean 0.04) had lower QoL. Hypertension affected

Zyga et al.

functionality [t(145.715)
3.062, p .003], with

patients suffering from hypertension (mean 7.5) enjoying greater QoL. Heart diseases affected functionality [t(222)
2.374, p .018] and wellness
[t(222)
2.224, p .027], though patients not
suffering from heart diseases experienced lower QoL
(mean 4.3 for functionality and
8.4 for wellness). Bone diseases affected all dimensions except
symptoms [t(57.907)
0.767, p .446]; patients
without bone diseases scored lower on functionality
(mean 5.0), wellness (mean
7.8), and spirituality (mean
10.3), but higher on interpersonal relationships (mean 12.4). Kinetic problems affected
functionality [t(222)
3.479, p .001], interpersonal relationships [t(222) 3.445, p .001], and
spirituality [t(222)
4.405, p < .027]. Patients
without kinetic problems experienced lower functionality (mean 4.3) and spirituality (mean
10.8),
but greater interpersonal relationships (mean
13.0). Experience of cramps affected only interpersonal relationships [t(222) 2.256, p .025] with patients suffering to enjoy less QoL (mean: 10.2).
Experience of headaches affected interpersonal relationships [t(222) 2.132, p .034] and spirituality
[t(222)
4.224, p .034], with patients suffering
from headaches having lower scores on interpersonal
relationships (mean 10.1) but higher scores on spirituality (mean
6.1). Finally, experience of itchiness
affected symptoms [t(222) 2.458, p .015] and
interpersonal relationships [t(222)
3.236,
p .001], and patients suffering from itchiness had
lower symptoms (mean 1.3) and interpersonal relationships (mean 8.2) scores.

DISCUSSION
This study was carried out in the Peloponnese region
of Greece and targeted to assess self-efficacy in pain
and its effect on pain among 224 HD patients. The
PSEQ was used in hemodialysis patients for the first
time. It was constructed in order to assess selfefficacy in HD patients with ongoing pain. It also
looked at the level of confidence that patients feel during their daily activities. According to our findings, the
presence of pain is common among HD patients. In
particular, pain can cause severe disruption to QoL.
Ways in which Pain can Be Measured
For the evaluation of pain intensity, several instruments have been constructed (Haefeli & Elfering,
2006). Most of them focus on populations suffering
from rheumatologic diseases. The pain visual analogue
scale (VAS) is a single-item, self-completed, and continuous scale comprised of a horizontal (HVAS) or vertical

(VVAS) line. Numerical rating scale (NRS) is a

segmented numeric version of the VAS. Both two
scales (VAS and NRS) assess pain intensity. The NRS
can be administered either verbally or in writing, in
contrast to the VAS, which is administered as paper
only. The McGill pain questionnaire (MPQ) evaluates
both the quality and quantity of pain. It may be used
in epidemiologic studies and clinical trials, but its
complexity may make it difficult for patients to us.
Due to the difficulties of vocabulary in the SF-MPQ, a
member of the research team should be present during
completion. In regards to scoring, the Chronic Pain
Grade Scale (CPGS), which assesses the effect of pain
on daily activities, can be difficult. In contrast, Short
Form-36 Bodily Pain Scale (SF-36 BPS) is simple to complete and appropriate to correlate different samples of
population (Hawker et al., 2011; Mannion, Balgue,
Pellise, & Cedraschi, 2007). No specific tool was
recommended for measuring frequency of pain
(Mannion et al., 2007). In conclusion, several scales
have been designed for pain determination and, especially, its intensity. However, we cannot argue that
there is an appropriate instrument for patients of all
ages or disorders (Herr, Pratt, Mobily, & Richardson,
2004; Pautex et al., 2006).
Amount of Pain
Our study showed that, on average, patients are neutral
regarding self-efficacy in pain. The reported frequency
of pain varies widely in HD patients (Murtagh et al.,
2007). The weighted average prevalence among symptoms of CKD is 47%, with a range between 8% and 82%
(Mercadante et al., 2005). Many studies explore the intensity and types of pain. Gamondi et al. (2013) found
that all patients reported pain and fatigue as major
complaints. In the same study, 66% of patients stated
that pain was the predominant complaint, while
60.5% characterized pain as intense. In other studies,
pain is characterized as severe pain by all patients
(Davison & Jhangri, 2010), while the majority of patients in a study by Calls et al. (2009), who completed
the questionnaire not during treatment, but in their
homes, characterized the intensity of pain as mild to
moderate. Davison and Jhangri (2005) reported that
50.2% of patients reported pain between symptoms,
with 41.4% characterizing it as moderate to severe.
Similar results are found by Barakzoy and Moss
(2006) and Bouattar et al. (2009).
Regarding the duration of pain, Bouattar et al.
(2009) found that pain was described as intermittent
at a rate of 47.1% and continual at a rate of 20.6%.
As far as the type of pain is concerned, in a study
by Gamondi et al. (2013), the most common type of
pain reported was musculoskeletal (64%), which is

Pain and Quality of Life in Hemodialysis

indeed a major nuisance apart from dialysis, followed

by headache (31%), and cramps (20%), which are the
major discomforts during HD session. Similarly, Calls
et al. (2009) highlighted the presence of musculoskeletal pain, followed by ischemic pain and pain associated with the treatment process.
In our study, a major risk factor associated with
pain was advanced age. Particularly, younger patients
(<40 years old) seemed to achieve better pain selfefficacy than older patients. Bouattar et al. (2009)
found similar results. In addition, Barakzoy and Moss
(2006) achieved adequate analgesia in 43 of 45 patients
(96%), with older patients tending to be less responsive to treatment than younger people. However,
Davison and Jhangri (2005) and Calls et al. (2009)
found no statistically significant differences between
pain assessment and age or gender.
Correlation of Pain and Quality of Life
An important aspect that undoubtedly influences QoL
of HD patients is pain, which patients are very likely to
experience given the development of multiple comorbid illnesses and the chronicity of the disease (Davison,
2007; Mercadante et al., 2005). This study found that
the more effective the self-efficacy in pain, the lower
QoL regarding the overall QoL for HD patients. According to our findings, younger patients (younger than
40 years old) seemed to enjoy lower QoL. These findings are in contrast with the findings of Mujais et al.
(2009), who found that older patients (>65 years)
had generally lower QoL on functionality and overall
health. Mujais et al. (2009) also found that women
generally enjoy lower QoL compared to men
(p < .0001), while in our study the difference between
the sexes was not statistically significant (p > .05).
We also found that diabetic patients or patients
without heart disease enjoy lower QoL, while those
with hypertension enjoyed better QoL but were less
effective in managing pain. Similar results were found
by Mujais et al. (2009), highlighting both diabetes mellitus and heart disease as factors of low QoL.
The high burden of physical and psychological
symptoms is multifactorial, and in this study was associated with decreased daily activity and a significant
impact on QoL and independence. Several researchers
(Harris et al., 2012, Perlman et al., 2005) have also
shown that pain negatively impacts many fields of
QoL, including physical function, social function,
daily activities, energy, fatigue, and emotional
function. Gamondi et al. (2013) found that 75% of
the participants reported that pain restricts fully or
partially their daily activities. Furthermore, Davison
(2010) emphasizes the strong negative correlation between the total burden of symptoms and QoL related

to either the physical or mental health. Finally,

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

LIMITATIONS OF THE STUDY

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

IMPLICATIONS FOR PRACTICE

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

Zyga et al.

the intensity of their symptoms. It is essential that

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

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

psychometric properties of the MVQOLI (Theofilou

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

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

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