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

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+Model YCTIM-1432;No.of Pages6 ARTICLE IN PRESS Complementary Therapies in Medicine (2015)xxx,xxx-xxx Available online at www.sciencedirect.com Complementary ScienceDirect ELSEVIER 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☆ Ali Asghar Ghods2,Neda Hoseini Abforosha,Raheb Ghorbanib, Mohammad Reza Asgaria,* 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 KEYWORDS Summary Hemodialysis; Background:Patients undergoing hemodialysis experience constant fear and anxiety due to Needle; the pain of the insertion of dialysis needles,which might lead to certain physiological and Lavender; psychological complications for them in the long term.It is therefore essential to control their Pain 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.:+982333654190;fax:+982333654190;mobile:+989125312890 E-mail address:asgari5000@gmail.com(M.R.Asgari). http:/1dk.doi.org/10.1016/j.ctim.2015.03.001 0965-2299/2015 Elsevier Ltd.All rights reserved. Please cite this article in press as:Ghods AA,et al.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.Complement Ther Med(2015),http:/1d.doi.org/10.1016/j.ctim.2015.03.001

+Model YCTIM-1432;No.of Pages 6 ARTICLE IN PRESS 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 physical,psychological and social components and is a major problem for about 50%of hemodialysis patients.26 There- Chronic renal failure is globally rising in prevalence.In 2000, fore,preventing further pain and finding a simple,safe the number of patients treated for chronic renal failure was method for its reduction are necessary.Due to the neces- about 1,100,000 across the world and reached 2,654,000 by sity of hemodialysis for the survival of patients and repeated the end of 2009.The 6-7%increase indicates a growth rate needle insertion for dialysis patients,we decided to study more than that of the global population itself.In Iran,the the effect of a medicinal plant that has been shown to growth rate of the disease is higher than the mean interna- have analgesic effects in some cases,so this study aimed to tional growth rate and is about 12%per year.-Many patients investigate the effects of lavender essential oil on reduction with chronic renal failure can be successfully treated with of pain during insertion of dialysis needles in hemodialysis hemodialysis.3 On average,a hemodialysis patient under- patients. goes ten AVF punctures per month and continues to undergo the procedure throughout his life or until a successful renal Methods transplant.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 hemodialy- Design and participants sis patients have fear of needles.6 More than one fifth of them consider the pain of the insertion of vascular nee- This open crossover study was conducted on 34 patients dles to be unbearable.The repetition of this pain can lead admitted to the dialysis unit of a Semnan University of to depression and reduced quality of life in hemodialysis Medical Sciences'hospital in 2012.The Ethics Commit- patients.?The results of a study conducted in 2008 showed tee of Semnan University of Medical Sciences approved that hemodialysis patients collectively suffer from needle the study (code No.IRCT201303076342N3).After receiving pain,which is one of the factors causing patients over 65 the approval of the Ethics Committee and obtaining writ- years to give up hemodialysis.3 ten consent from the patients,the subjects were selected McCaffery argues that pain is whatever the person expe- through the convenience sampling method and according to the inclusion and exclusion criteria.The inclusion criteria riencing it describes it to be and exists whenever the person experiencing it says that it does.The perception of pain consisted of being over 18 in age,being in a state of full includes different mental processes,such as the individual's consciousness,requiring at least 2 sessions of hemodialysis feelings and beliefs about pain.10 The early experience of per week,the absence of eczema and fragrance allergies, pain therefore leads to a poor attitude toward treatment a minimum of 6 weeks since the surgical creation of fistula. and increases fear and avoidance of treatment.11 Since a not having taken tranquilizers,sedatives or analgesics for at needle-phobic patient normally resists treatment,this state least the preceding 6 h and not suffering from neuropathy is considered a significant barrier for the efficiency of the and diabetes.Patients with either one of the following con- health care system.12 Lai et al.revealed one of the reasons ditions were excluded from the study:history of addiction, for dialysis withdrawal to be the repeated pain of needle smoking,peripheral vascular disease,known psychological insertions at the start of dialysis.3 disorders based on the patient's records,failed first attempt Pain control is one of the main tasks of nursing.14 at vascular access and unwillingness to participate in the Pain reduction leads to the acceptance of the procedure study for whatever reason.In addition,if a patient expe- and ultimately improves the patients'quality of life15 rienced pain or inflammation at the site of fistula during and is associated with their satisfaction with the hospi- the intervention or had used a hot water bottle,he would tal personnel,16 therefore,nursing personnel should always not be tested on that day.According to the study con- seek ways for an effective pain control.Complementary and ducted by Saeki,using a hot water bottle can increase the alternative medicine is a growing industry in health care sys- patients'perception of pain.27 All patients were also tested tems with an application that is constantly evolving.17 The for sensitivity to lavender by pouring a drop of 100%laven- use of complementary treatments and natural alternatives der essential oil on the forearm skin and for olfactory health decreases complications and reduces the need for synthetic through lemon juice testing.The flow of study participants analgesics.18 Some studies have shown that lavender has is shown in Fig.1. analgesic,19-21 wound healing,22 antibacterial,anti-fungal, anti-flatulent,sedative and antidepressant effects and can Data collection effectively heal burns and insect bites.23 Lavender and its main components,linalyl acetate and linalool,have been The data collection instrument included the patients' proposed as topical palliatives of pain in animal models.24 demographic information form (enquiring about gender, Acute pain is a major problem in intensive care age,education,marital status,occupation and history of patients.25 This multidimensional phenomenon has several hemodialysis)and also the pain numeric rating scale(NRS). Please cite this article in press as:Ghods AA,et al.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.Complement Ther Med(2015),http:/1dx.doi.org/10.1016/j.ctim.2015.03.001

Please cite this article in press as: Ghods AA, et al. The effect oftopical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial. Complement Ther Med (2015), http://dx.doi.org/10.1016/j.ctim.2015.03.001 ARTICLE IN PRESS +Model YCTIM-1432; No. of Pages 6 2 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)

+Model YCTIM-1432;No.of Pages 6 ARTICLE IN PRESS Effect of topical application of lavender on pain 3 Assessed for eligibility (N=40) for 5 min.The essential oil used was prepared from laven- der 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 Excluded (N=3) No.1316. Sensitivity to fragrance=2 For the placebo state,3 puffs of water were sprayed on Problem of smell sense=1 the puncture site and left for 5 min.In all the three different states,the skin on the site of the needle insertion was dis- infected with betadine and the arterial needle was inserted Entry in trial (N=37) 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 (Control)pain intensity was measured arteriovenous fistula)and at the elbow(the brachiocephalic without any intervention (N=37) 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 5cm to the fistula at an angle of 30 Excluded (N=3) to 45.The nurse who inserted the arterial needle in all the three states remained fixed. Randomized=(N=34) 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 Allocated to Placebo (N=17) Allocated to Topical was set at p<0.05. lavender (N=17) Results Wash out period(72 hours) Wash out period (72 hours) Participants'characteristics The mean age of the 34 subjects studied was 59.6+12.5 Allocated to Topical Allocated to placebo (N=17) and the majority (38.2%)were aged 60-69.All the sub- lavender (N=17) jects were married.Their mean duration of hemodialysis was 36.9+26.1 months.Other demographic characteristics Figure 1 Consort diagram of the flow of patients in this study. are presented in Table 1. The intensity of pain in the three states of topical The validity and reliability of this instrument has already been confirmed by several studies.28.29 intervention,placebo and no interventions According to the results of the study,the mean intensity of Interventions pain in the no-intervention state(the control state)showed no significant differences between the genders (p=0.066) All the patients were tested at three different states: and the occupations (p=0.955).In addition,the intensity of the topical lavender application state,the placebo state, pain showed no significant correlation with age(r=-0.276 and the control state with no interventions.At first,pain and p=0.114)and with the level of education (r=-0.064 intensity was just measured without any interventions. and p=0.721);however,it showed a negative correlation The second and third interventions (i.e.the topical laven- with the duration of hemodialysis(p=-0.426 and p=0.012). der application or the placebo application)were randomly The mean intensity of pain was 2.91+1.69 in patients determined through the randomized block design so that all after the topical application of lavender essential oil, samples could be tested by all three methods.There was a 4.18+1.66 after the application of the placebo and minimum of 72 h interval between the interventions.In the 4.59+2.02 at the no-intervention state.There was a sig- topical application method,3 puffs(0.3 ml)of 100%laven- nificant difference in the intensity of pain among the three der essential oil were sprayed on the puncture site and left states (p=0.001)(Table 2). Please cite this article in press as:Ghods AA,et al.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.Complement Ther Med(2015),http:/1dx.doi.org/10.1016/j.ctim.2015.03.001

+Model YCTIM-1432;No.of Pages 6 ARTICLE IN PRESS A.A.Ghods et al. Table 1 Absolute and relative frequency of subjects in Discussion terms of demographic characteristics. The results of the present study suggest a positive effect for Characteristic Category n() the application of topical lavender essential oil on reducing Gender Male 18(52.9%) pain caused by the insertion of dialysis needles in hemodial- Female 16(47.1%) ysis patients.Patients reported a lower intensity of pain in the lavender intervention state compared to the placebo Age (year) 70 7(20.6%) der essential oil.Few studies have been conducted on the Level of Illiterate 16(47.1%) analgesic effects of the direct application of lavender on education Below high school diploma 14(41.2%) the site of pain.In a study conducted by Altaei and Ahmed, High school diploma 4(11.8%) the intervention group applied topical lavender cream three times per day for 5 days.The results of their study showed Marital status Single a significant difference in the intensity of pain between the Married 34(100%) lavender intervention group and the acyclovir intervention Occupation Self-employed 7(20.6%) group as the intensity of pain had significant reduced in the Housekeeper 15(44.1%) lavender intervention group compared to the acyclovir and Retired 10(29.4%) placebo intervention groups.30 Sheikhan et al.studied 60 Disabled 2(5.9%) primiparous women and showed the pain caused by epis- iotomy to have significantly decreased in the intervention Mean 37 15(44.1%) Although in some studies,lavender was not the only com- pound used,it has been a fixed component of interventions in the various studies conducted on this subject.In a study Table 2 The mean and confidence interval of the intensity conducted by Chang et al.on the effects of aroma hand of pain in the three states of topical intervention,placebo massage on pain,state anxiety and depression in hospice and no interventions. patients with terminal cancer,in which the intervention Intensity of pain Mean (SD) 95%CP p-Value 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% Topical intervention 2.91(1.69) 2.32-3.50 0.001 Bergamot,Lavender and Frankincense with a 1:1:1 ratio Placebo intervention 4.18(1.66) 3.60-4.76 diluted in almond oil.The results showed that the inten- No interventions 4.59(2.02) 3.88-5.29 sity of pain was lower in the experimental group compared a SD:standard deviation to the control group(the group massaged with almond oil),32 b Cl:confidence interval which is consistent with the findings of the present study. Contrary to these studies,there are studies that do not Pairwise comparison of the intensities of pain in confirm the results of the present study.In a study conducted the different states by Vakilian et al.on 120 primiparous women,the pain of episiotomy showed no significance difference in the experi- mental group that had used 5-7 drops of lavender essential On average,the intensity of pain reduced by 1.68 after the oil in 4L of water twice a day for 10 days compared to the topical intervention compared to the no-intervention (the control group.33 This difference may be due to that a very control state)(p<0.001),by 0.41 after the placebo inter- low dose of lavender oil was used. vention compared to the no-intervention(p=0.025)and by 1.27 after the topical intervention compared to the placebo The analgesic effects of the topical application of laven- der essential oil might be due to fragrance inhalation intervention (p<0.001)(Table 3). Table 3 Pairwise comparison of the intensity of pain in the different states Pairwise comparison Difference p-Value Mean±SD 95%C1P Topical intervention compared to no interventions 1.68±1.20 1.26-2.10 <0.001 Placebo intervention compared to no intervention 0.41±0.99 0.07-0.76 0.025 Topical intervention compared to placebo intervention 1.27±1.14 0.87-1.66 <0.001 a SD:standard deviation b Cl:confidence interval Please cite this article in press as:Ghods AA,et al.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.Complement Ther Med(2015),http:/1dx.doi.org/10.1016/j.ctim.2015.03.001

+Model YCTIM-1432;No.of Pages 6 ARTICLE IN PRESS Effect of topical application of lavender on pain 5 and skin absorption.34 Inhaling the lavender fragrance is elective procedure that the patient often chooses willingly. inevitable when applying topical lavender on the hands.In Moreover,needle size affects the intensity of perceived fact,lavender essential oil applied topically develops its pain.In the present study,although lavender was applied effects in the application site and its inhalation effects can topically,its inhalation effect was also at play,thus making be also observed. it different from the study conducted by Grunebaum et al. The pain-reducing topical effect of the application of One of the limitations of the present study was lavender essential oil is believed to owe to its main com- the patients'psychological conditions potentially having pounds such as linalyl acetate and linalool that have topical affected their response to pain,which could not be con- analgesic properties.Researchers believe that the topical trolled,even though the use of tranguilizers and analgesics pain-reducing effect of lavender is associated with antimus- and the willingness to participate in the study were closely carinic activities or channel blocking (Ca2+,NA+),23.24 as observed.In addition,one nurse alone could not take care of the block of sodium currents in the pain-transmitting nerve all the needle insertions for all the patients;however,each fibers blocks pain nerve messages.Animal models showed patient had only one nurse assigned to them for the task of that lavender and its main components(linalyl acetate and inserting the needles during all the stages of the study. linalool)were effective on topical pain relief.24 The results of a study conducted by Jager et al.showed that the lina- Conclusions lyl acetate and linalool content of lavender are absorbed through the skin 5min after they are massaged and can be discerned in the blood flow.34 The topical application Given the findings,it can be concluded that the topical of lavender can increase topical blood circulation,and its application of lavender can reduce moderate pain caused by the insertion of dialysis needles in hemodialysis patients. linalool content can decrease muscle tone and create seda- tive effects.36 Hence,based on the results of this study,it can be recom- The analgesic effects of lavender inhalation are believed mended for nurses to apply topical lavender on the patients to stimulate the limbic system.37 Lavender essential oil prior to the insertion of hemodialysis needles as a simple safe method of reducing pain. 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 Conflicts of interest linalool)has a sedative effect.3 In addition,its pleasant scent might reinforce analgesia as the limbic areas are All authors declare that they have not had any conflicts of involved in pleasant feelings.39 The inhalation of lavender interest in conducting the present study. essence creates an emotional response and is therefore a natural emotional regulator that reduces stress and increases hormonal coordination in the body.40 Through Acknowledgements stimulating the limbic system,aromatherapy can stimulate the nervous physiological response,the immune system or This paper is part of a postgraduate thesis approved by the endocrine and affect the heart rate,blood pressure, Semnan University of Medical Sciences under the code 480. respiration or brain wave activities and release various hor- Hereby,we would like to express our gratitude to the mones from the body.1 These effects on the brain can research deputy of Semnan University of Medical Sciences sedate or stimulate the nervous system and potentially help for all their financial support and also the authorities,nurs- hormone secretions get to normal levels.38 In addition,the ing personnel and patients of the dialysis unit of Semnan pleasant scents used in aromatherapy increase the tidal vol- Fatemieh Hospital for their sincere cooperation ume and decrease the respiratory rate,thereby creating a deep,peaceful breathing.3 Developing a deep,peace- References ful breathing pattern is another mechanism for reducing feelings of pain.42 1.Fresenius Medical Care.ESRD patient in 2009,global Some studies have examined the effects of lavender view of ESRD patients;September,2011.Available from inhalation.In the controlled study conducted by Bagheri http://vision-fmc.com/?Action=show Detailaid=pag1311lg=l et al.on the effects of lavender aromatherapy on the 2.Aghighi M,Heidary Rouchi A,Zamyadi M,Mahdavi-Mazdeh M, pain caused by the insertion of needles into the fistula in Rajolani H,Ahrabi S,et al.Dialysis in Iran.Iran J Kidney Dis hemodialysis patients,the examination of the effects of 2008:2(1:11-5. 10%lavender inhalation for 5min from a 10cm distance of 3.Sennfalt K,Magnusson M,Carlsson P.Comparison of hemodial- the nose showed that lavender aromatherapy can reduce ysis and peritoneal dialysis-a cost-utility analysis.Perit Dial pain.3 The findings of the study conducted by Kim et al. 1nt2002:22(1):39-47. showed that wearing a lavender oxygen mask for 5min 4.Sabitha P,Khakha D,Mahajan S,Gupta S,Agarwal M,Yadav S.Effect of cryotherapy on arteriovenous fistula puncture- can reduce stress levels and the depth of anesthesia and related pain in hemodialysis patients.Indian J Nephrol pain caused by needle insertion.19 The results of the study 2008:18(4):155-8. conducted by Grunebaum et al.on the effects of lavender 5.Figueiredo AE,Viegas A,Monteiro M,Poli-de-Figueiredo CE. inhalation on the intensity of pain caused by the injection of Research into pain perception with arteriovenous fistula (avf) botulinum toxin type A(BTX-A or Botox)for the correction cannulation.J Renal Care 2008:34(4):169-72. of facial wrinkles showed that lavender essential oil is not 6.McLaughlin K,Manns B,Mortis G,Hons R,Taub K.Why patients effective on the perception of pain during injection.4 This with ESRD do not select self-care dialysis as a treatment option. disparity might be because cosmetic facial surgery is an Am J Kidney Dis 2003;41:380-5. Please cite this article in press as:Ghods AA,et al.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.Complement Ther Med(2015),http://dx.doi.org/10.1016/j.ctim.2015.03.001

Please cite this article in press as: Ghods AA, et al. The effect oftopical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial. Complement Ther Med (2015), http://dx.doi.org/10.1016/j.ctim.2015.03.001 ARTICLE IN PRESS +Model YCTIM-1432; No. of Pages 6 Effect of topical application of lavender on pain 5 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 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. References 1. Fresenius Medical Care. ESRD patient in 2009, global view of ESRD patients; September, 2011. Available from http://vision-fmc.com/?Action=show Detail&id=pag1311&lg=I 2. 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Please cite this article in press as: Ghods AA, et al. The effect oftopical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial. Complement Ther Med (2015), http://dx.doi.org/10.1016/j.ctim.2015.03.001 ARTICLE IN PRESS +Model YCTIM-1432; No. of Pages 6 6 A.A. Ghods et al. 7. Harris TJ, Nazir R, Khetpal P, Peterson RA, Chava P, Patel SS, et al. Pain, sleep disturbance and survival in hemodialysis patients. Nephrol Dial Transpl 2012;27(2):758—65. 8. Quinn R, Lamping D, Lok C, Meyer R, Hiller J, Lee J, et al. The Vascular Access Questionnaire: assessing patient-reported views of vascular access. J Vasc Access 2008;9(2):122—8. 9. Balkema K, Claytor K, Clevenger K, Conn K, Conner S, Freisner IK, et al. Medical surgical nursing certification. 5th ed Philadelphia: Lippincott; 2012. p. 90—3. 10. Wiech K, Ploner M, Tracey I. Neurocognitive aspects of pain perception. Trends Cognit Sci 2008;12(8):306—13. 11. DeMore M, Cohen LL. Distraction for pediatric immunization pain: a critical review. J Clin Psychol Med Settings 2005;12(4):281—91. 12. Kim H, Kim Y, Lee H, Kim S, Lee H, Chang D, et al. Development and validation of acupuncture fear scale. Evid Based Complement Altern Med 2013;2013:1—8. 13. Lai C-F, Tsai H-B, Hsu S-H, Chiang C-K, Huang J-W, Huang SJ. Withdrawal from long-term hemodialysis in patients with end-stage renal disease in Taiwan. J Formos Med Assoc 2013;2013:1—11. 14. Angelucci D, Quinn L, Handlin D. A pain management relief plan: a thoughtful, organized approach to pain improves the quality of patient care. Nurs Manag 1998;29(10):49—55. 15. Celik G, Ozbek O, Yilmaz M, Duman I, Ozbek S, Apiliogullari S. Vapocoolant spray vs lidocaine/prilocaine cream for reducing the pain of venipuncture in hemodialysis patients: a randomized, placebo-controlled, crossover study. Int J Med Sci 2011;8(7):623—7. 16. Hariharan S, Ramsewak R, Chen D, Merritt-Charles L, Bridglal C. A Study of the efficacy of diclofenac iontophoresis for providing effective topical analgesia. Int J Pain 2007;5(10):1—10. 17. Loh KP, Ghorab H, Clarke E, Conroy R, Barlow J. Medical students’ knowledge, perceptions, and interest in complementary and alternative medicine. J Altern Complement Med 2013;19(4):360—6. 18. Ghannadi A, Karimzadeh H, Tavakoli N, Darafsh M, Ramezanloo P. Efficacy of a combined rosemary and lavender topical ointment in the treatment of patients with osteoarthritis of the knee. Zahedan J Res Med Sci 2013;15(6):29—33. 19. Kim S, Kim HJ, Yeo JS, Hong SJ, Lee JM, Jeon Y. The effect of lavender oil on stress, bispectral index values, and needle insertion pain in volunteers. J Altern Complement Med 2011;17(9):823—6. 20. Altaei DT. Topical lavender oil for the treatment of recurrent aphthous ulceration. Am J Dent 2012;25(1):39—43. 21. Kane FM, Brodie EE, Coull A, Coyne L, Howd A, Milne A, et al. The analgesic effect of odour and music upon dressing change. Br J Nurs 2004;13(Suppl. 19):S4—12. 22. Rezaie A, Lotfollahi B, Mohajeri D, Mousavi G, Nazeri M, Zakhireh S, et al. Geometric and histopathologic assessment of lavender extracts (Lavandula stoechas) on healing of experimental skin wounds and its comparison with zinc oxide on rats. Res J Biol Sci 2011;6(11):585—9. 23. Cavanagh HM, Wilkinson JM. Biological activities of lavender essential oil. Phytother Res 2002;16(4):301—8. 24. Ghelardini C, Galeotti N, Salvatore G, Mazzanti G. Local anaesthetic activity of the essential oil of Lavandula angustifolia. Planta Med 1999;65(8):700—3. 25. Stannard D, Puntillo K, Miaskowski C, Gleeson S, Kehrle K, Nye P. Clinical judgment and management of postoperative pain in critical care patients. Am J Crit Care 1996;5(6):433—41. 26. Davison SN, Jhangri GS. The impact of chronic pain on depression, sleep, and the desire to withdraw from dialysis in hemodialysis patients. J Pain Symp Manag 2005;30(5): 465—73. 27. Saeki Y, Tanaka YL. Effect of inhaling fragrances on relieving pricking pain. Int J Aroma 2005;15(2):74—80. 28. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res 2011;63(S11): S240—52. 29. Breivik H, Borchgrevink P, Allen S, Rosseland L, Romundstad L, Hals EB, et al. Assessment of pain. Br J Anaesth 2008;101(1):17—24. 30. Altaei T, Ahmed SA. Topical treatment of herpes simplex lesion by lavender cream. J Bagh Coll Dent 2012;24(Special issue 1):70—6. 31. Sheikhan F, Jahdi F, Khoei EM, Shamsalizadeh N, Sheikhan M, Haghani H. Episiotomy pain relief: use of lavender oil essence in primiparous Iranian women. Complement Ther Clin Pract 2012;18(1):66—70. 32. Chang SY. Effects of aroma hand massage on pain, state anxiety and depression in hospice patients with terminal cancer. J Korean Acad Nurs 2008;38(4):493—502. 33. Vakilian K, Atarha M, Bekhradi R, Chaman R. Healing advantages of lavender essential oil during episiotomy recovery: a clinical trial. Complement Ther Clin Pract 2011;17(1):50—3. 34. Jager W, Buchbauer G, Jirovetz L, Fritzer M. Percutaneous absorption of lavender oil from a massage oil. J Soc Cosmet Chem 1992;43(1):49—54. 35. Fetzer SJ. Reducing the pain of venipuncture. J Perianesth Nurs 1999;14(2):95—101. 36. Lis Balchin M, Hart S. Studies on the mode of action of the essential oil of lavender (Lavandula angustifolia P. Millers). Phytother Res 1999;13(6):540—2. 37. Gaware V, Nagare R, Dhamak KB, Khadse AN, Kotade KB, Kashid VA, et al. Aromatherapy: art or science. Int J Biomed Res 2013;4(2):74—83. 38. Linck VM, da Silva AL, Figueiró M, Luis Piato Â, Paula Herrmann A, Dupont Birck F, et al. Inhaled linalool-induced sedation in mice. Phytomedicine 2009;16(4):303—7. 39. Masaoka Y, Takayama M, Yajima H, Kawase A, Takakura N, Homma I. Analgesia is enhanced by providing information regarding good outcomes associated with an odor: placebo effects in aromatherapy? Evid Based Complement Altern Med 2013;2013. 40. Huang S-H, Fang L, Fang S-H. The effectiveness of aromatherapy with lavender essential oil in relieving post arthroscopy pain. JMED Res 2014;2014:1—9. 41. Cohen MH. Legal issues in complementary and integrative medicine. A guide for the clinician. Med Clin N Am 2002;86(1):185—96. 42. Busch V, Magerl W, Kern U, Haas J, Hajak G, Eichhammer P. The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing—–an experimental study. Pain Med 2012;13(2):215—28. 43. Bagheri-Nesami M, Espahbodi F, Nikkhah A, Shorofi SA, Charati JY. The effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients. Complement Ther Clin Pract 2014;20(1):1—4. 44. Grunebaum LD, Murdock J, Castanedo-Tardan MP, Baumann LS. Effects of lavender olfactory input on cosmetic procedures. J Cosmet Dermatol 2011;10(2):89—93

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