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The effect of topical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial
Complementary Therapies in Medicine (2015) 23, 325—330
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
The effect of topical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial夽 Ali Asghar Ghods a, Neda Hoseini Abforosh a, Raheb Ghorbani b, Mohammad Reza Asgari a,∗ a
Department of Medical-Surgical Nursing, Faculty of Nursing and Allied Health, Semnan University of Medical Sciences, Semnan, Iran b Research Center for Social Determinants of Health and Department of Community Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran Available online 21 March 2015
KEYWORDS Hemodialysis; Needle; Lavender; Pain
夽 ∗
Summary Background: Patients undergoing hemodialysis experience constant fear and anxiety due to the pain of the insertion of dialysis needles, which might lead to certain physiological and psychological complications for them in the long term. It is therefore essential to control their pain through a simple, safe method. Objective: The present study was conducted to determine the effect of the topical application of lavender essential oil on the intensity of pain during the insertion of dialysis needles in hemodialysis patients. Design: This open crossover study was conducted on 34 hemodialysis patients with arteriovenous fistula (AVF) admitted to the dialysis unit of one of the hospitals of Semnan University of Medical Sciences in 2013. The intensity of pain was measured in all the patients in three different states during the insertion of arterial needles for hemodialysis: (1) The topical application of 100% lavender essential oil, (2) no intervention, (3) placebo (with water). Main outcome measures: Pain intensity was measured in this study through the numeric rating scale (NRS) of pain. Results: The findings showed that the mean ± SD of pain intensity was 2.91 ± 1.69 with the topical application of lavender, 4.59 ± 2.02 in the no intervention state and 4.18 ± 1.66 with the placebo state. Statistical tests showed a significant difference between the patients’ intensity of pain in the three different states (p = 0.001).
IRCT CODE: IRCT201303076342N3. Corresponding author. Tel.: +98 23 33654190; fax: +98 23 33654190; mobile: +98 912 5312890. E-mail address: [email protected] (M.R. Asgari).
http://dx.doi.org/10.1016/j.ctim.2015.03.001 0965-2299/© 2015 Elsevier Ltd. All rights reserved.
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A.A. Ghods et al. Conclusion: Based on the findings of the study, the topical application of lavender decreases moderate intensities of pain during the insertion of dialysis needles. Accordingly, lavender oil may be an option to reduce pain by insertion of hemodialysis needles. © 2015 Elsevier Ltd. All rights reserved.
Introduction Chronic renal failure is globally rising in prevalence. In 2000, the number of patients treated for chronic renal failure was about 1,100,000 across the world and reached 2,654,000 by the end of 2009. The 6—7% increase indicates a growth rate more than that of the global population itself.1 In Iran, the growth rate of the disease is higher than the mean international growth rate and is about 12% per year.2 Many patients with chronic renal failure can be successfully treated with hemodialysis.3 On average, a hemodialysis patient undergoes ten AVF punctures per month and continues to undergo the procedure throughout his life or until a successful renal transplant.4 Repeated AVF punctures create considerable amounts of pain for the patient due to the diameter and length of the needles used.5 A total of 47% of hemodialysis patients have fear of needles.6 More than one fifth of them consider the pain of the insertion of vascular needles to be unbearable. The repetition of this pain can lead to depression and reduced quality of life in hemodialysis patients.7 The results of a study conducted in 2008 showed that hemodialysis patients collectively suffer from needle pain, which is one of the factors causing patients over 65 years to give up hemodialysis.8 McCaffery argues that pain is whatever the person experiencing it describes it to be and exists whenever the person experiencing it says that it does.9 The perception of pain includes different mental processes, such as the individual’s feelings and beliefs about pain.10 The early experience of pain therefore leads to a poor attitude toward treatment and increases fear and avoidance of treatment.11 Since a needle-phobic patient normally resists treatment, this state is considered a significant barrier for the efficiency of the health care system.12 Lai et al. revealed one of the reasons for dialysis withdrawal to be the repeated pain of needle insertions at the start of dialysis.13 Pain control is one of the main tasks of nursing.14 Pain reduction leads to the acceptance of the procedure and ultimately improves the patients’ quality of life15 and is associated with their satisfaction with the hospital personnel,16 therefore, nursing personnel should always seek ways for an effective pain control. Complementary and alternative medicine is a growing industry in health care systems with an application that is constantly evolving.17 The use of complementary treatments and natural alternatives decreases complications and reduces the need for synthetic analgesics.18 Some studies have shown that lavender has analgesic,19—21 wound healing,22 antibacterial, anti-fungal, anti-flatulent, sedative and antidepressant effects and can effectively heal burns and insect bites.23 Lavender and its main components, linalyl acetate and linalool, have been proposed as topical palliatives of pain in animal models.24 Acute pain is a major problem in intensive care patients.25 This multidimensional phenomenon has several
physical, psychological and social components and is a major problem for about 50% of hemodialysis patients.26 Therefore, preventing further pain and finding a simple, safe method for its reduction are necessary. Due to the necessity of hemodialysis for the survival of patients and repeated needle insertion for dialysis patients, we decided to study the effect of a medicinal plant that has been shown to have analgesic effects in some cases, so this study aimed to investigate the effects of lavender essential oil on reduction of pain during insertion of dialysis needles in hemodialysis patients.
Methods Design and participants This open crossover study was conducted on 34 patients admitted to the dialysis unit of a Semnan University of Medical Sciences’ hospital in 2012. The Ethics Committee of Semnan University of Medical Sciences approved the study (code No. IRCT201303076342N3). After receiving the approval of the Ethics Committee and obtaining written consent from the patients, the subjects were selected through the convenience sampling method and according to the inclusion and exclusion criteria. The inclusion criteria consisted of being over 18 in age, being in a state of full consciousness, requiring at least 2 sessions of hemodialysis per week, the absence of eczema and fragrance allergies, a minimum of 6 weeks since the surgical creation of fistula, not having taken tranquilizers, sedatives or analgesics for at least the preceding 6 h and not suffering from neuropathy and diabetes. Patients with either one of the following conditions were excluded from the study: history of addiction, smoking, peripheral vascular disease, known psychological disorders based on the patient’s records, failed first attempt at vascular access and unwillingness to participate in the study for whatever reason. In addition, if a patient experienced pain or inflammation at the site of fistula during the intervention or had used a hot water bottle, he would not be tested on that day. According to the study conducted by Saeki, using a hot water bottle can increase the patients’ perception of pain.27 All patients were also tested for sensitivity to lavender by pouring a drop of 100% lavender essential oil on the forearm skin and for olfactory health through lemon juice testing. The flow of study participants is shown in Fig. 1.
Data collection The data collection instrument included the patients’ demographic information form (enquiring about gender, age, education, marital status, occupation and history of hemodialysis) and also the pain numeric rating scale (NRS).
Effect of topical application of lavender on pain
327 for 5 min. The essential oil used was prepared from lavender using the water and steam method at the Teaching and Research Farm of Semnan Agriculture Jahad Training Center by Dr. Ghahreman flora, under the code 114/004/001 and No. 1316. For the placebo state, 3 puffs of water were sprayed on the puncture site and left for 5 min. In all the three different states, the skin on the site of the needle insertion was disinfected with betadine and the arterial needle was inserted afterwards. Needle insertions were carried out by multiple nurses; however, each patient had only one nurse insert the needle for them during the different stages. The intensity of pain was assessed after the arterial needle was inserted and before inserting the venous needle. The site of patients’ arteriovenous fistula was at the wrist area (the radiocephalic arteriovenous fistula) and at the elbow (the brachiocephalic arteriovenous fistula). For ensuring consistency, a 16-gauge needle (made by Supa, Iran) was used for vascular access and the arterial needle was inserted into the arteries from a minimum distance of 5 cm to the fistula at an angle of 30◦ to 45◦ . The nurse who inserted the arterial needle in all the three states remained fixed.
Statistical analysis The Kolmogorov—Smirnov test was used to analyze the data distribution and the Pearson correlation coefficient, the paired t-test, the Wilcoxon test and the Friedman test were used for data analysis. The statistical level of significance was set at p < 0.05.
Results Participants’ characteristics
Figure 1
Consort diagram of the flow of patients in this study.
The validity and reliability of this instrument has already been confirmed by several studies.28,29
Interventions All the patients were tested at three different states: the topical lavender application state, the placebo state, and the control state with no interventions. At first, pain intensity was just measured without any interventions. The second and third interventions (i.e. the topical lavender application or the placebo application) were randomly determined through the randomized block design so that all samples could be tested by all three methods. There was a minimum of 72 h interval between the interventions. In the topical application method, 3 puffs (0.3 ml) of 100% lavender essential oil were sprayed on the puncture site and left
The mean age of the 34 subjects studied was 59.6 ± 12.5 and the majority (38.2%) were aged 60—69. All the subjects were married. Their mean duration of hemodialysis was 36.9 ± 26.1 months. Other demographic characteristics are presented in Table 1.
The intensity of pain in the three states of topical intervention, placebo and no interventions According to the results of the study, the mean intensity of pain in the no-intervention state (the control state) showed no significant differences between the genders (p = 0.066) and the occupations (p = 0.955). In addition, the intensity of pain showed no significant correlation with age (r = −0.276 and p = 0.114) and with the level of education (r = −0.064 and p = 0.721); however, it showed a negative correlation with the duration of hemodialysis (p = −0.426 and p = 0.012). The mean intensity of pain was 2.91 ± 1.69 in patients after the topical application of lavender essential oil, 4.18 ± 1.66 after the application of the placebo and 4.59 ± 2.02 at the no-intervention state. There was a significant difference in the intensity of pain among the three states (p = 0.001) (Table 2).
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A.A. Ghods et al.
Table 1 Absolute and relative frequency of subjects in terms of demographic characteristics. Characteristic
Category
n (%)
Gender
Male Female
18 (52.9%) 16 (47.1%)
Age (year)
<50 50—59 60—69 >70
7 (20.6%) 7 (20.6) 13 (38.2%) 7 (20.6%)
Level of education
Illiterate Below high school diploma High school diploma
16 (47.1%) 14 (41.2%) 4 (11.8%)
Marital status
Single Married
0 34 (100%)
Occupation
Self-employed Housekeeper Retired Disabled
7 (20.6%) 15 (44.1%) 10 (29.4%) 2 (5.9%)
Mean duration of hemodialysis (month)
<12 12—24 25—36 >37
5 (14.7%) 6 (17.6%) 8 (23.5%) 15 (44.1%)
Table 2 The mean and confidence interval of the intensity of pain in the three states of topical intervention, placebo and no interventions. Intensity of pain
Mean (SDa )
95% CIb
p-Value
Topical intervention Placebo intervention No interventions
2.91 (1.69) 4.18 (1.66) 4.59 (2.02)
2.32—3.50 3.60—4.76 3.88—5.29
0.001
a b
SD: standard deviation. CI: confidence interval.
Pairwise comparison of the intensities of pain in the different states On average, the intensity of pain reduced by 1.68 after the topical intervention compared to the no-intervention (the control state) (p < 0.001), by 0.41 after the placebo intervention compared to the no-intervention (p = 0.025) and by 1.27 after the topical intervention compared to the placebo intervention (p < 0.001) (Table 3).
Table 3
Topical intervention compared to no interventions Placebo intervention compared to no intervention Topical intervention compared to placebo intervention a
The results of the present study suggest a positive effect for the application of topical lavender essential oil on reducing pain caused by the insertion of dialysis needles in hemodialysis patients. Patients reported a lower intensity of pain in the lavender intervention state compared to the placebo intervention state or the state with no interventions. The purpose of the topical application of lavender in the present study was to determine the effect of topical lavender essential oil. Few studies have been conducted on the analgesic effects of the direct application of lavender on the site of pain. In a study conducted by Altaei and Ahmed, the intervention group applied topical lavender cream three times per day for 5 days. The results of their study showed a significant difference in the intensity of pain between the lavender intervention group and the acyclovir intervention group as the intensity of pain had significant reduced in the lavender intervention group compared to the acyclovir and placebo intervention groups.30 Sheikhan et al. studied 60 primiparous women and showed the pain caused by episiotomy to have significantly decreased in the intervention group who had used small tubs filled with 5 L of water and 0.25 ml of lavender essential oil twice a day for 5 days compared to the control group.31 Although in some studies, lavender was not the only compound used, it has been a fixed component of interventions in the various studies conducted on this subject. In a study conducted by Chang et al. on the effects of aroma hand massage on pain, state anxiety and depression in hospice patients with terminal cancer, in which the intervention group received a 5-min aroma hand massage on each hand for 7 days with a blended oil made up of a mixture of 1.5% Bergamot, Lavender and Frankincense with a 1:1:1 ratio diluted in almond oil. The results showed that the intensity of pain was lower in the experimental group compared to the control group (the group massaged with almond oil),32 which is consistent with the findings of the present study. Contrary to these studies, there are studies that do not confirm the results of the present study. In a study conducted by Vakilian et al. on 120 primiparous women, the pain of episiotomy showed no significance difference in the experimental group that had used 5—7 drops of lavender essential oil in 4 L of water twice a day for 10 days compared to the control group.33 This difference may be due to that a very low dose of lavender oil was used. The analgesic effects of the topical application of lavender essential oil might be due to fragrance inhalation
Pairwise comparison of the intensity of pain in the different states.
Pairwise comparison
b
Discussion
SD: standard deviation. CI: confidence interval.
Difference
p-Value
Mean ± SDa
95%CIb
1.68 ± 1.20 0.41 ± 0.99 1.27 ± 1.14
1.26—2.10 0.07—0.76 0.87—1.66
<0.001 0.025 <0.001
Effect of topical application of lavender on pain and skin absorption.34 Inhaling the lavender fragrance is inevitable when applying topical lavender on the hands. In fact, lavender essential oil applied topically develops its effects in the application site and its inhalation effects can be also observed. The pain-reducing topical effect of the application of lavender essential oil is believed to owe to its main compounds such as linalyl acetate and linalool that have topical analgesic properties. Researchers believe that the topical pain-reducing effect of lavender is associated with antimuscarinic activities or channel blocking (Ca2+, NA+),23,24 as the block of sodium currents in the pain-transmitting nerve fibers blocks pain nerve messages.35 Animal models showed that lavender and its main components (linalyl acetate and linalool) were effective on topical pain relief.24 The results of a study conducted by Jager et al. showed that the linalyl acetate and linalool content of lavender are absorbed through the skin 5 min after they are massaged and can be discerned in the blood flow.34 The topical application of lavender can increase topical blood circulation, and its linalool content can decrease muscle tone and create sedative effects.36 The analgesic effects of lavender inhalation are believed to stimulate the limbic system.37 Lavender essential oil could potentially affect the central nervous system and reduce the autonomic response to painful stimuli.27 The inhalation of some of its constituents (linalyl acetate and linalool) has a sedative effect.38 In addition, its pleasant scent might reinforce analgesia as the limbic areas are involved in pleasant feelings.39 The inhalation of lavender essence creates an emotional response and is therefore a natural emotional regulator that reduces stress and increases hormonal coordination in the body.40 Through stimulating the limbic system, aromatherapy can stimulate the nervous physiological response, the immune system or the endocrine and affect the heart rate, blood pressure, respiration or brain wave activities and release various hormones from the body.41 These effects on the brain can sedate or stimulate the nervous system and potentially help hormone secretions get to normal levels.38 In addition, the pleasant scents used in aromatherapy increase the tidal volume and decrease the respiratory rate, thereby creating a deep, peaceful breathing.39 Developing a deep, peaceful breathing pattern is another mechanism for reducing feelings of pain.42 Some studies have examined the effects of lavender inhalation. In the controlled study conducted by Bagheri et al. on the effects of lavender aromatherapy on the pain caused by the insertion of needles into the fistula in hemodialysis patients, the examination of the effects of 10% lavender inhalation for 5 min from a 10 cm distance of the nose showed that lavender aromatherapy can reduce pain.43 The findings of the study conducted by Kim et al. showed that wearing a lavender oxygen mask for 5 min can reduce stress levels and the depth of anesthesia and pain caused by needle insertion.19 The results of the study conducted by Grunebaum et al. on the effects of lavender inhalation on the intensity of pain caused by the injection of botulinum toxin type A (BTX-A or Botox) for the correction of facial wrinkles showed that lavender essential oil is not effective on the perception of pain during injection.44 This disparity might be because cosmetic facial surgery is an
329 elective procedure that the patient often chooses willingly. Moreover, needle size affects the intensity of perceived pain. In the present study, although lavender was applied topically, its inhalation effect was also at play, thus making it different from the study conducted by Grunebaum et al. One of the limitations of the present study was the patients’ psychological conditions potentially having affected their response to pain, which could not be controlled, even though the use of tranquilizers and analgesics and the willingness to participate in the study were closely observed. In addition, one nurse alone could not take care of all the needle insertions for all the patients; however, each patient had only one nurse assigned to them for the task of inserting the needles during all the stages of the study.
Conclusions Given the findings, it can be concluded that the topical application of lavender can reduce moderate pain caused by the insertion of dialysis needles in hemodialysis patients. Hence, based on the results of this study, it can be recommended for nurses to apply topical lavender on the patients prior to the insertion of hemodialysis needles as a simple, safe method of reducing pain.
Conflicts of interest All authors declare that they have not had any conflicts of interest in conducting the present study.
Acknowledgements This paper is part of a postgraduate thesis approved by Semnan University of Medical Sciences under the code 480. Hereby, we would like to express our gratitude to the research deputy of Semnan University of Medical Sciences for all their financial support and also the authorities, nursing personnel and patients of the dialysis unit of Semnan Fatemieh Hospital for their sincere cooperation.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
The effect of topical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial夽 Ali Asghar Ghods a, Neda Hoseini Abforosh a, Raheb Ghorbani b, Mohammad Reza Asgari a,∗ a
Department of Medical-Surgical Nursing, Faculty of Nursing and Allied Health, Semnan University of Medical Sciences, Semnan, Iran b Research Center for Social Determinants of Health and Department of Community Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran Available online 21 March 2015
KEYWORDS Hemodialysis; Needle; Lavender; Pain
夽 ∗
Summary Background: Patients undergoing hemodialysis experience constant fear and anxiety due to the pain of the insertion of dialysis needles, which might lead to certain physiological and psychological complications for them in the long term. It is therefore essential to control their pain through a simple, safe method. Objective: The present study was conducted to determine the effect of the topical application of lavender essential oil on the intensity of pain during the insertion of dialysis needles in hemodialysis patients. Design: This open crossover study was conducted on 34 hemodialysis patients with arteriovenous fistula (AVF) admitted to the dialysis unit of one of the hospitals of Semnan University of Medical Sciences in 2013. The intensity of pain was measured in all the patients in three different states during the insertion of arterial needles for hemodialysis: (1) The topical application of 100% lavender essential oil, (2) no intervention, (3) placebo (with water). Main outcome measures: Pain intensity was measured in this study through the numeric rating scale (NRS) of pain. Results: The findings showed that the mean ± SD of pain intensity was 2.91 ± 1.69 with the topical application of lavender, 4.59 ± 2.02 in the no intervention state and 4.18 ± 1.66 with the placebo state. Statistical tests showed a significant difference between the patients’ intensity of pain in the three different states (p = 0.001).
IRCT CODE: IRCT201303076342N3. Corresponding author. Tel.: +98 23 33654190; fax: +98 23 33654190; mobile: +98 912 5312890. E-mail address: [email protected] (M.R. Asgari).
http://dx.doi.org/10.1016/j.ctim.2015.03.001 0965-2299/© 2015 Elsevier Ltd. All rights reserved.
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A.A. Ghods et al. Conclusion: Based on the findings of the study, the topical application of lavender decreases moderate intensities of pain during the insertion of dialysis needles. Accordingly, lavender oil may be an option to reduce pain by insertion of hemodialysis needles. © 2015 Elsevier Ltd. All rights reserved.
Introduction Chronic renal failure is globally rising in prevalence. In 2000, the number of patients treated for chronic renal failure was about 1,100,000 across the world and reached 2,654,000 by the end of 2009. The 6—7% increase indicates a growth rate more than that of the global population itself.1 In Iran, the growth rate of the disease is higher than the mean international growth rate and is about 12% per year.2 Many patients with chronic renal failure can be successfully treated with hemodialysis.3 On average, a hemodialysis patient undergoes ten AVF punctures per month and continues to undergo the procedure throughout his life or until a successful renal transplant.4 Repeated AVF punctures create considerable amounts of pain for the patient due to the diameter and length of the needles used.5 A total of 47% of hemodialysis patients have fear of needles.6 More than one fifth of them consider the pain of the insertion of vascular needles to be unbearable. The repetition of this pain can lead to depression and reduced quality of life in hemodialysis patients.7 The results of a study conducted in 2008 showed that hemodialysis patients collectively suffer from needle pain, which is one of the factors causing patients over 65 years to give up hemodialysis.8 McCaffery argues that pain is whatever the person experiencing it describes it to be and exists whenever the person experiencing it says that it does.9 The perception of pain includes different mental processes, such as the individual’s feelings and beliefs about pain.10 The early experience of pain therefore leads to a poor attitude toward treatment and increases fear and avoidance of treatment.11 Since a needle-phobic patient normally resists treatment, this state is considered a significant barrier for the efficiency of the health care system.12 Lai et al. revealed one of the reasons for dialysis withdrawal to be the repeated pain of needle insertions at the start of dialysis.13 Pain control is one of the main tasks of nursing.14 Pain reduction leads to the acceptance of the procedure and ultimately improves the patients’ quality of life15 and is associated with their satisfaction with the hospital personnel,16 therefore, nursing personnel should always seek ways for an effective pain control. Complementary and alternative medicine is a growing industry in health care systems with an application that is constantly evolving.17 The use of complementary treatments and natural alternatives decreases complications and reduces the need for synthetic analgesics.18 Some studies have shown that lavender has analgesic,19—21 wound healing,22 antibacterial, anti-fungal, anti-flatulent, sedative and antidepressant effects and can effectively heal burns and insect bites.23 Lavender and its main components, linalyl acetate and linalool, have been proposed as topical palliatives of pain in animal models.24 Acute pain is a major problem in intensive care patients.25 This multidimensional phenomenon has several
physical, psychological and social components and is a major problem for about 50% of hemodialysis patients.26 Therefore, preventing further pain and finding a simple, safe method for its reduction are necessary. Due to the necessity of hemodialysis for the survival of patients and repeated needle insertion for dialysis patients, we decided to study the effect of a medicinal plant that has been shown to have analgesic effects in some cases, so this study aimed to investigate the effects of lavender essential oil on reduction of pain during insertion of dialysis needles in hemodialysis patients.
Methods Design and participants This open crossover study was conducted on 34 patients admitted to the dialysis unit of a Semnan University of Medical Sciences’ hospital in 2012. The Ethics Committee of Semnan University of Medical Sciences approved the study (code No. IRCT201303076342N3). After receiving the approval of the Ethics Committee and obtaining written consent from the patients, the subjects were selected through the convenience sampling method and according to the inclusion and exclusion criteria. The inclusion criteria consisted of being over 18 in age, being in a state of full consciousness, requiring at least 2 sessions of hemodialysis per week, the absence of eczema and fragrance allergies, a minimum of 6 weeks since the surgical creation of fistula, not having taken tranquilizers, sedatives or analgesics for at least the preceding 6 h and not suffering from neuropathy and diabetes. Patients with either one of the following conditions were excluded from the study: history of addiction, smoking, peripheral vascular disease, known psychological disorders based on the patient’s records, failed first attempt at vascular access and unwillingness to participate in the study for whatever reason. In addition, if a patient experienced pain or inflammation at the site of fistula during the intervention or had used a hot water bottle, he would not be tested on that day. According to the study conducted by Saeki, using a hot water bottle can increase the patients’ perception of pain.27 All patients were also tested for sensitivity to lavender by pouring a drop of 100% lavender essential oil on the forearm skin and for olfactory health through lemon juice testing. The flow of study participants is shown in Fig. 1.
Data collection The data collection instrument included the patients’ demographic information form (enquiring about gender, age, education, marital status, occupation and history of hemodialysis) and also the pain numeric rating scale (NRS).
Effect of topical application of lavender on pain
327 for 5 min. The essential oil used was prepared from lavender using the water and steam method at the Teaching and Research Farm of Semnan Agriculture Jahad Training Center by Dr. Ghahreman flora, under the code 114/004/001 and No. 1316. For the placebo state, 3 puffs of water were sprayed on the puncture site and left for 5 min. In all the three different states, the skin on the site of the needle insertion was disinfected with betadine and the arterial needle was inserted afterwards. Needle insertions were carried out by multiple nurses; however, each patient had only one nurse insert the needle for them during the different stages. The intensity of pain was assessed after the arterial needle was inserted and before inserting the venous needle. The site of patients’ arteriovenous fistula was at the wrist area (the radiocephalic arteriovenous fistula) and at the elbow (the brachiocephalic arteriovenous fistula). For ensuring consistency, a 16-gauge needle (made by Supa, Iran) was used for vascular access and the arterial needle was inserted into the arteries from a minimum distance of 5 cm to the fistula at an angle of 30◦ to 45◦ . The nurse who inserted the arterial needle in all the three states remained fixed.
Statistical analysis The Kolmogorov—Smirnov test was used to analyze the data distribution and the Pearson correlation coefficient, the paired t-test, the Wilcoxon test and the Friedman test were used for data analysis. The statistical level of significance was set at p < 0.05.
Results Participants’ characteristics
Figure 1
Consort diagram of the flow of patients in this study.
The validity and reliability of this instrument has already been confirmed by several studies.28,29
Interventions All the patients were tested at three different states: the topical lavender application state, the placebo state, and the control state with no interventions. At first, pain intensity was just measured without any interventions. The second and third interventions (i.e. the topical lavender application or the placebo application) were randomly determined through the randomized block design so that all samples could be tested by all three methods. There was a minimum of 72 h interval between the interventions. In the topical application method, 3 puffs (0.3 ml) of 100% lavender essential oil were sprayed on the puncture site and left
The mean age of the 34 subjects studied was 59.6 ± 12.5 and the majority (38.2%) were aged 60—69. All the subjects were married. Their mean duration of hemodialysis was 36.9 ± 26.1 months. Other demographic characteristics are presented in Table 1.
The intensity of pain in the three states of topical intervention, placebo and no interventions According to the results of the study, the mean intensity of pain in the no-intervention state (the control state) showed no significant differences between the genders (p = 0.066) and the occupations (p = 0.955). In addition, the intensity of pain showed no significant correlation with age (r = −0.276 and p = 0.114) and with the level of education (r = −0.064 and p = 0.721); however, it showed a negative correlation with the duration of hemodialysis (p = −0.426 and p = 0.012). The mean intensity of pain was 2.91 ± 1.69 in patients after the topical application of lavender essential oil, 4.18 ± 1.66 after the application of the placebo and 4.59 ± 2.02 at the no-intervention state. There was a significant difference in the intensity of pain among the three states (p = 0.001) (Table 2).
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Table 1 Absolute and relative frequency of subjects in terms of demographic characteristics. Characteristic
Category
n (%)
Gender
Male Female
18 (52.9%) 16 (47.1%)
Age (year)
<50 50—59 60—69 >70
7 (20.6%) 7 (20.6) 13 (38.2%) 7 (20.6%)
Level of education
Illiterate Below high school diploma High school diploma
16 (47.1%) 14 (41.2%) 4 (11.8%)
Marital status
Single Married
0 34 (100%)
Occupation
Self-employed Housekeeper Retired Disabled
7 (20.6%) 15 (44.1%) 10 (29.4%) 2 (5.9%)
Mean duration of hemodialysis (month)
<12 12—24 25—36 >37
5 (14.7%) 6 (17.6%) 8 (23.5%) 15 (44.1%)
Table 2 The mean and confidence interval of the intensity of pain in the three states of topical intervention, placebo and no interventions. Intensity of pain
Mean (SDa )
95% CIb
p-Value
Topical intervention Placebo intervention No interventions
2.91 (1.69) 4.18 (1.66) 4.59 (2.02)
2.32—3.50 3.60—4.76 3.88—5.29
0.001
a b
SD: standard deviation. CI: confidence interval.
Pairwise comparison of the intensities of pain in the different states On average, the intensity of pain reduced by 1.68 after the topical intervention compared to the no-intervention (the control state) (p < 0.001), by 0.41 after the placebo intervention compared to the no-intervention (p = 0.025) and by 1.27 after the topical intervention compared to the placebo intervention (p < 0.001) (Table 3).
Table 3
Topical intervention compared to no interventions Placebo intervention compared to no intervention Topical intervention compared to placebo intervention a
The results of the present study suggest a positive effect for the application of topical lavender essential oil on reducing pain caused by the insertion of dialysis needles in hemodialysis patients. Patients reported a lower intensity of pain in the lavender intervention state compared to the placebo intervention state or the state with no interventions. The purpose of the topical application of lavender in the present study was to determine the effect of topical lavender essential oil. Few studies have been conducted on the analgesic effects of the direct application of lavender on the site of pain. In a study conducted by Altaei and Ahmed, the intervention group applied topical lavender cream three times per day for 5 days. The results of their study showed a significant difference in the intensity of pain between the lavender intervention group and the acyclovir intervention group as the intensity of pain had significant reduced in the lavender intervention group compared to the acyclovir and placebo intervention groups.30 Sheikhan et al. studied 60 primiparous women and showed the pain caused by episiotomy to have significantly decreased in the intervention group who had used small tubs filled with 5 L of water and 0.25 ml of lavender essential oil twice a day for 5 days compared to the control group.31 Although in some studies, lavender was not the only compound used, it has been a fixed component of interventions in the various studies conducted on this subject. In a study conducted by Chang et al. on the effects of aroma hand massage on pain, state anxiety and depression in hospice patients with terminal cancer, in which the intervention group received a 5-min aroma hand massage on each hand for 7 days with a blended oil made up of a mixture of 1.5% Bergamot, Lavender and Frankincense with a 1:1:1 ratio diluted in almond oil. The results showed that the intensity of pain was lower in the experimental group compared to the control group (the group massaged with almond oil),32 which is consistent with the findings of the present study. Contrary to these studies, there are studies that do not confirm the results of the present study. In a study conducted by Vakilian et al. on 120 primiparous women, the pain of episiotomy showed no significance difference in the experimental group that had used 5—7 drops of lavender essential oil in 4 L of water twice a day for 10 days compared to the control group.33 This difference may be due to that a very low dose of lavender oil was used. The analgesic effects of the topical application of lavender essential oil might be due to fragrance inhalation
Pairwise comparison of the intensity of pain in the different states.
Pairwise comparison
b
Discussion
SD: standard deviation. CI: confidence interval.
Difference
p-Value
Mean ± SDa
95%CIb
1.68 ± 1.20 0.41 ± 0.99 1.27 ± 1.14
1.26—2.10 0.07—0.76 0.87—1.66
<0.001 0.025 <0.001
Effect of topical application of lavender on pain and skin absorption.34 Inhaling the lavender fragrance is inevitable when applying topical lavender on the hands. In fact, lavender essential oil applied topically develops its effects in the application site and its inhalation effects can be also observed. The pain-reducing topical effect of the application of lavender essential oil is believed to owe to its main compounds such as linalyl acetate and linalool that have topical analgesic properties. Researchers believe that the topical pain-reducing effect of lavender is associated with antimuscarinic activities or channel blocking (Ca2+, NA+),23,24 as the block of sodium currents in the pain-transmitting nerve fibers blocks pain nerve messages.35 Animal models showed that lavender and its main components (linalyl acetate and linalool) were effective on topical pain relief.24 The results of a study conducted by Jager et al. showed that the linalyl acetate and linalool content of lavender are absorbed through the skin 5 min after they are massaged and can be discerned in the blood flow.34 The topical application of lavender can increase topical blood circulation, and its linalool content can decrease muscle tone and create sedative effects.36 The analgesic effects of lavender inhalation are believed to stimulate the limbic system.37 Lavender essential oil could potentially affect the central nervous system and reduce the autonomic response to painful stimuli.27 The inhalation of some of its constituents (linalyl acetate and linalool) has a sedative effect.38 In addition, its pleasant scent might reinforce analgesia as the limbic areas are involved in pleasant feelings.39 The inhalation of lavender essence creates an emotional response and is therefore a natural emotional regulator that reduces stress and increases hormonal coordination in the body.40 Through stimulating the limbic system, aromatherapy can stimulate the nervous physiological response, the immune system or the endocrine and affect the heart rate, blood pressure, respiration or brain wave activities and release various hormones from the body.41 These effects on the brain can sedate or stimulate the nervous system and potentially help hormone secretions get to normal levels.38 In addition, the pleasant scents used in aromatherapy increase the tidal volume and decrease the respiratory rate, thereby creating a deep, peaceful breathing.39 Developing a deep, peaceful breathing pattern is another mechanism for reducing feelings of pain.42 Some studies have examined the effects of lavender inhalation. In the controlled study conducted by Bagheri et al. on the effects of lavender aromatherapy on the pain caused by the insertion of needles into the fistula in hemodialysis patients, the examination of the effects of 10% lavender inhalation for 5 min from a 10 cm distance of the nose showed that lavender aromatherapy can reduce pain.43 The findings of the study conducted by Kim et al. showed that wearing a lavender oxygen mask for 5 min can reduce stress levels and the depth of anesthesia and pain caused by needle insertion.19 The results of the study conducted by Grunebaum et al. on the effects of lavender inhalation on the intensity of pain caused by the injection of botulinum toxin type A (BTX-A or Botox) for the correction of facial wrinkles showed that lavender essential oil is not effective on the perception of pain during injection.44 This disparity might be because cosmetic facial surgery is an
329 elective procedure that the patient often chooses willingly. Moreover, needle size affects the intensity of perceived pain. In the present study, although lavender was applied topically, its inhalation effect was also at play, thus making it different from the study conducted by Grunebaum et al. One of the limitations of the present study was the patients’ psychological conditions potentially having affected their response to pain, which could not be controlled, even though the use of tranquilizers and analgesics and the willingness to participate in the study were closely observed. In addition, one nurse alone could not take care of all the needle insertions for all the patients; however, each patient had only one nurse assigned to them for the task of inserting the needles during all the stages of the study.
Conclusions Given the findings, it can be concluded that the topical application of lavender can reduce moderate pain caused by the insertion of dialysis needles in hemodialysis patients. Hence, based on the results of this study, it can be recommended for nurses to apply topical lavender on the patients prior to the insertion of hemodialysis needles as a simple, safe method of reducing pain.
Conflicts of interest All authors declare that they have not had any conflicts of interest in conducting the present study.
Acknowledgements This paper is part of a postgraduate thesis approved by Semnan University of Medical Sciences under the code 480. Hereby, we would like to express our gratitude to the research deputy of Semnan University of Medical Sciences for all their financial support and also the authorities, nursing personnel and patients of the dialysis unit of Semnan Fatemieh Hospital for their sincere cooperation.
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