Effect of Acupuncture or Massage on Health-Related Quality of Life of Hemodialysis Patients

Introduction

End stage renal disease (ESRD) affects more than 670,000 patients in the United States. ¹ The progression to ESRD often results in the development of additional serious comorbidities including depression, anxiety, pain, sexual dysfunction, insomnia, sleep apnea, and restless leg syndrome, which can profoundly impact health-related quality of life (HR-QOL). ^{2 –4} Lifestyle restrictions and modifications required for hemodialysis (HD) may have a detrimental effect on mood. Evidence reports 5%–58% of HD patients experience depression. ² Similarly, 12%–52% of patients on HD have anxiety. ² Causes of depression and anxiety include fluid and diet restrictions, painful fistula cannulation, financial burden, and poor social support among other psychological stress. ⁵ HD patients suffer from poor sleep quality with 20%–83% reporting sleep disorders. ² Patients experience fatigue due to accumulation of metabolic waste, anemia, fluid-electrolyte imbalance, depression, and other health-related conditions. ⁶ Pain is another symptom experienced by dialysis patients. Evidence shows that over 58% of HD patients report pain and 49% rate their pain as moderate or severe. ⁷ Musculoskeletal pain is commonly reported (63.1%), followed by dialysis-associated pain (13.6%), peripheral neuropathy (12.6%), and peripheral vascular disease (9.7%). ⁸ Chronic pain is associated with disability, insomnia, depression, psychological distress, and lower HR-QOL. ^7,9 Moreover, HD patients may have other medical conditions (diabetes mellitus and cardiovascular disease being the most common), which contribute to chronic pain, HR-QOL, and other psychological distress. ^7,10,11

Decreased QOL in patients undergoing HD is a well described problem. Patients on HD have been found to have lower scores than their counterparts on peritoneal dialysis and those who have undergone kidney transplantation. ¹² The dialysis outcomes and practice patterns study (DOPPS) by Mapes et al., found that dialysis patients with the lowest scores on three indicators of HR-QOL, namely the physical component summary, mental component summary, and kidney disease component summary, had an adjusted risk of death of 93% and their risk of hospitalization was 56% higher than those with the highest scores. ¹³

The control of these symptoms requires a multidisciplinary approach, which may include complementary and alternative medicine (CAM). Acupuncture and massage are complementary nonpharmacological interventions that have been used to manage symptoms of chronic illness and reduce their severity. ^{14 –17} Acupuncture is a popular complementary therapy used to treat various health conditions, chronic pain, and cancer care. It involves using acupuncture needling on body points to improve blood circulation, increase secretion of neurotransmitters, and maintain homeostasis. ^{18 –20} Acupuncture has reduced symptoms of pain, fatigue, nausea, vomiting, depression, anxiety, and improved QOL among patients with HD and other chronic conditions. ^{14 –18,21} Another complementary therapy that has provided health and psychological benefits to patients with chronic illness includes massage. Massage therapy involves the physical act of applying pressure to soft tissue and muscles to provide physiological relief, increase blood circulation, and comfort. ^6,22 Studies have shown that massage improved sleep quality, fatigue, pain, and cramps among HD patients. ^6,22

The purpose of this study was to investigate the effect of acupuncture and massage, on HR-QOL measures of physical and psychological distress, life satisfaction, pain severity, fatigue, and mood states among ESRD patients..

Materials and Methods

Results

A total of 108 patients were included in this study. The majority of patients, N = 80, elected for massage and 21 elected for acupuncture. The patient demographics were available for 101 patients and are summarized in Table 1. The average age was 57.6 ± 14.5 years, with 58% male and the most common etiology of ESRD was diabetes. The average duration of time on HD or dialysis vintage was 7.5 ± 8.3 years. The population of patients had multiple comorbidities with the most common being hypertension, diabetes, cardiovascular disease, and depression.

The individual question scores from the PROMIS Global Health Short Form survey are described in Table 2. Out of the 10 individual questions, an improvement in the rate of satisfaction with social activities and relationships (p = 0.045) was observed (Table 2).

No statistically significant difference was detected pretest and post-test for GAD-7 individual responses (Table 3). There was no change in PROMIS physical raw score with the mean PROMIS physical raw score 12.75 ± 2.87 before intervention and 12.84 ± 2.856 after intervention (Table 4). There was a significant improvement (p = 0.034) in the mental raw score after the intervention (Table 4). There was no significant difference in the pre- and post-test scores for the GAD-7 total score (p = 0.1493).

Discussion

We found that the majority of participants chose massage therapy as opposed to acupuncture. Ninety-three percent of our patients undergo dialysis using an arteriovenous fistula for access, which requires dialysis needle placement three times a week and is not a pleasant procedure. It is not surprising then that patients would prefer to avoid additional use of needles. In addition, a large proportion of our patients are Hispanic and literature has demonstrated a low overall use of CAM among Hispanics and preference for massage therapy. ²³ Su and Li studied trends in the use of CAM between 2002 and 2007 by racial and ethnic groups and found Hispanics used 42.07% more massage therapy from 2002 to 2007, whereas the use of acupuncture decreased by 5.22% over the same time period. ²³

In our study, we found an increase in global mental global score with the use of complementary therapies, despite the short duration of our study. This score is derived from four individual questions addressing QOL, mental health, satisfaction with social activities, and frequency of feeling anxious, depressed, or irritable. Depression is the most common psychiatric illness in patients with ESRD and it is a significant predictor of mortality in this population. ²⁴ Treatment of depression in chronic dialysis patients is far from optimal. The evidence for antidepressant medication effectiveness in the dialysis population is sparse. ²⁵ A recent study by Hedayati et al. revealed no benefit of treatment with sertraline in patients with nondialysis-dependent chronic kidney disease (CKD). ²⁶ Whether the results of this study can be generalized to other selective serotonin reuptake inhibitors used to treat depression is unknown. It is also unknown whether the results apply to dialysis-dependent CKD patients. We do know, however, that there is need for better and alternative ways to improve mental health in dialysis patients, including nonpharmacological treatment. The chronic dialysis population is unique and quite different from the general population and nondialysis-dependent CKD. The phenomenon of reverse epidemiology in dialysis population is well described, though not understood. ²⁷ Also, it has been shown that many medications that are beneficial in general population offer no benefit and if anything can be associated with harm in chronic dialysis patients. Complimentary therapies have potential to offer alternative and safe way to improve physical and mental wellbeing in chronic dialysis population.

Hmwe et al. reported significant improvements in depression, anxiety, stress, and general psychological distress among patients who received acupressure, a technique of stimulating acupuncture points using the fingertip instead of the needle. ²¹ Shariati et al. also found acupressure improved sleep quality in HD patients. ¹⁸ Studies of acupuncture conducted in a hospice setting reported patient improvements in QOL, reduced symptoms of pain, fatigue, depression, anxiety, shortness of breath, and enhanced feelings of wellbeing. ^14,16 Among cancer patients, acupuncture had a positive effect on nausea, vomiting, pain, sleep quality, anxiety, and QOL. ^15,17

Kim et al. found an improvement in fatigue symptoms in HD patients after receiving acupuncture for 7 weeks. ²⁸ In their study, they administered acupuncture twice a week either on nondialysis days or before undergoing dialysis. They found an improvement in physical functioning as measured by the Kidney Disease Quality of Life-Short Form; however, that change occurred after they continued the therapy for 11 weeks. In our study there was no change in Global Physical Health score with complimentary therapies. This score is derived from five individual questions addressing rate of physical health in everyday physical activities, fatigue, and pain. It is quite plausible that we did not find a significant change in physical functioning due to the short duration (8 weeks) of our study and frequency of the intervention (once a week). A recent study by Kimmel et al. revealed that opioid medication use in chronic dialysis patient is common and associated with increased risk of mortality, dialysis discontinuation, and hospitalization. ²⁹ This study only confirms need for alternative ways to address pain and physical wellbeing in dialysis population.

Massage is a therapeutic touch used for relaxation that can help HD patients overcome fatigue and other sleep disorders. Unal and Balci Akpinar found foot reflexology and back massage reduced fatigue and increased energy in HD patients. ⁶ The effect of massage therapy in patients on HD has been previously explored, although with different regimens and outcomes measures. Twenty six chronic dialysis participants experienced a significant decrease in the frequency of cramps compared to usual care, including stopping ultrafiltration, after receiving a 20-min massage in the lower extremities during each HD session three times weekly for 2 weeks. ³⁰ A second 3-week massage study of 80 HD participants with restless leg syndrome, ³¹ a common cause of insomnia and decreased QOL among dialysis patients, ^32,33 noted a significant decrease in symptoms. Both studies were limited to symptomatic participants and lower extremity massage. Importantly, these outcomes were secondary and the sample size included small numbers of participants. In contrast, in our study, massage was administered irrespective of the presence of physical symptoms and it was not limited to the lower extremities. Participants were actively involved in the therapy, guiding therapists on whether their pain was general or localized to a specific part of their body and their overall wellbeing goals. As such, our study addresses a different question; does massage therapy improve physical and mental wellbeing in patients receiving chronic dialysis?

We did not find a significant difference in the anxiety levels after the intervention likely due to the short intervention period. It is also likely that a combination of various interventions is needed to make a meaningful difference in frequency and severity of anxiety in this complex patient population. A recent randomized, controlled, assessor-blinded study using brief mindfulness meditation to address anxiety in HD patients the authors noted an improvement in the GAD-7 scores, however, the findings were not statistically significant. ³⁴ There are a growing number of studies evaluating different approaches to address anxiety among HD patients, beyond pharmacotherapy.

Our study has several strengths. First, the two therapies were administered while the participants were undergoing their routine HD session to avoid scheduling burdens for participants. In the prospective study by Kim et al., ²⁸ acupuncture was performed either on nondialysis days or before undergoing dialysis, which may not be feasible to sustain for an extended period of time.

Second, the therapies were administered by licensed professionals and tailored to each participant to alleviate their specific symptoms. An unintended benefit that we also noted from this study was that participants expressed an increased overall sense of appreciation due to the additional interaction they had with the therapist during their HD session. Surprisingly, implementation of the therapies during HD was simple with no interruptions in patient flow. HD staff commented that the unit was quiet with fewer patient complaints. Also, both massage and acupuncture were well tolerated. Most of our patients receive intravenous heparin during dialysis and no bleeding was noted from acupuncture needles.

This study has a number of limitations. It was a single center study and lacked randomization and blinding. We opted to not perform sham acupuncture because it would have been extremely cumbersome to perform while participants were undergoing dialysis. Another limitation of our study was the limited number of sessions provided to the patients. Since these therapies are not reimbursed for HD patients, we were only able to provide one session of massage or acupuncture per week instead of three times weekly based on funding. Consequently, it is uncertain if the effectiveness of these therapies were limited. This study did not differentiate PROMIS and GAD-7 scores by complementary therapy chosen. Both acupuncture and massage therapies were combined in the analysis. We cannot be certain if acupuncture or massage was more effective in reducing symptoms. Another limitation is that we were not able to match the results of the intervention to individual participants but rather the whole unit, since the pre and postsurveys were anonymous.

In summary, HD patients have low HR-QOL and the use of complementary medicine is a promising therapy to address the mental and physical symptoms they experience. Much attention is focused on therapies that prolong life but few address the QOL. No single intervention can address all of the issues our HD patients face and a comprehensive multifocal approach is needed. Complementary therapies including massages and acupuncture have the potential to improve the patient experience during HD and impact the mental wellbeing of our patients. We believe that regular QOL assessment and implementation of strategies to improve QOL should be an essential component of care plan for chronic dialysis patients.