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Document 1 of 1

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
Author: Ghods, Ali Asghar; Abforosh, Neda Hoseini; Ghorbani, Raheb; Asgari, Mohammad Reza
ProQuest document link
Abstract: 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 meanSD of pain intensity was 2.911.69 with the topical
application of lavender, 4.592.02 in the no intervention state and 4.181.66 with the placebo
state. Statistical tests showed a significant difference between the patients' intensity of pain in
the three different states (p=0.001).
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.

Full text: 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. In
1

Iran, the growth rate of the disease is higher than the mean international growth rate and is about
12% per year. Many patients with chronic renal failure can be successfully treated with
2

hemodialysis. On average, a hemodialysis patient undergoes ten AVF punctures per month and
3

continues to undergo the procedure throughout his life or until a successful renal transplant.
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Repeated AVF punctures create considerable amounts of pain for the patient due to the diameter
and length of the needles used. A total of 47% of hemodialysis patients have fear of needles.
5

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. The results of a study conducted in 2008 showed that hemodialysis
7

patients collectively suffer from needle pain, which is one of the factors causing patients over 65
years to give up hemodialysis.

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. The perception of pain includes different
9

mental processes, such as the individual's feelings and beliefs about pain. The early experience
10

of pain therefore leads to a poor attitude toward treatment and increases fear and avoidance of
treatment. Since a needle-phobic patient normally resists treatment, this state is considered a
11

significant barrier for the efficiency of the health care system. Lai et al. revealed one of the
12

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. Pain reduction leads to the acceptance of the
14

procedure and ultimately improves the patients' quality of life and is associated with their
15

satisfaction with the hospital personnel, therefore, nursing personnel should always seek ways
16

for an effective pain control. Complementary and alternative medicine is a growing industry in
health care systems with an application that is constantly evolving. The use of complementary
17

treatments and natural alternatives decreases complications and reduces the need for synthetic
analgesics. Some studies have shown that lavender has analgesic,
18

19-21

wound healing,

22

antibacterial, anti-fungal, anti-flatulent, sedative and antidepressant effects and can effectively
heal burns and insect bites. Lavender and its main components, linalyl acetate and linalool, have
23

been proposed as topical palliatives of pain in animal models.

24

Acute pain is a major problem in intensive care patients. This multidimensional phenomenon has
25

several physical, psychological and social components and is a major problem for about 50% of
hemodialysis patients. Therefore, preventing further pain and finding a simple, safe method for
26

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
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having taken tranquilizers, sedatives or analgesics for at least the preceding 6h 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). 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 72h
interval between the interventions. In the topical application method, 3 puffs (0.3ml) of 100%
lavender essential oil were sprayed on the puncture site and left for 5min. 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 5min. 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 5cm 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
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Participants' characteristics
The mean age of the 34 subjects studied was 59.612.5 and the majority (38.2%) were aged 6069. All the subjects were married. Their mean duration of hemodialysis was 36.926.1 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 2.911.69 in patients after the topical application of lavender
essential oil, 4.181.66 after the application of the placebo and 4.592.02 at the no-intervention
state. There was a significant difference in the intensity of pain among the three states (p=0.001)
(

Table 2

).

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

).

Discussion
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 5L of water and 0.25ml 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
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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 4L 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 and skin absorption. Inhaling the lavender fragrance is inevitable when applying
34

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. Animal models showed that
35

lavender and its main components (linalyl acetate and linalool) were effective on topical pain
relief. The results of a study conducted by Jager et al. showed that the linalyl acetate and linalool
24

content of lavender are absorbed through the skin 5min after they are massaged and can be
discerned in the blood flow. The topical application of lavender can increase topical blood
34

circulation, and its linalool content can decrease muscle tone and create sedative effects.
The analgesic effects of lavender inhalation are believed to stimulate the limbic system.

36

37

Lavender essential oil could potentially affect the central nervous system and reduce the
autonomic response to painful stimuli. The inhalation of some of its constituents (linalyl acetate
27

and linalool) has a sedative effect. In addition, its pleasant scent might reinforce analgesia as the
38

limbic areas are involved in pleasant feelings. The inhalation of lavender essence creates an
39

emotional response and is therefore a natural emotional regulator that reduces stress and
increases hormonal coordination in the body. Through stimulating the limbic system,
40

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. In addition, the
38

pleasant scents used in aromatherapy increase the tidal volume and decrease the respiratory
rate, thereby creating a deep, peaceful breathing. Developing a deep, peaceful breathing pattern
39

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 5min from a 10cm 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 5min can reduce stress levels and the depth of anesthesia and pain caused by
needle insertion. The results of the study conducted by Grunebaum et al. on the effects of
19

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
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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.

Characteristic
Gender
Female
Age (year)
50-59
13 (38.2%)
16 (47.1%)
High school diploma
Marital status
Married
Occupation
Housekeeper
10 (29.4%)

5 (14.7%)
25-36
Intensit Mean (SDa)
y of
29 February 2016

Category
Male
16 (47.1%)
<50
7 (20.6)
>70
Level of education
Below high school diploma
4 (11.8%)
Single
34 (100%)
Self-employed
15 (44.1%)
Disabled
Mean duration of hemodialysis
(month)
12-24
8 (23.5%)
95% CIb
Page 9 of 13

n (%)
18 (52.9%)
7 (20.6%)
60-69
7 (20.6%)
Illiterate
14 (41.2%)
0
7 (20.6%)
Retired
2 (5.9%)
<12
6 (17.6%)
>37
p-Value
ProQuest

pain
Topical
interve 2.91 (1.69)
ntion
Placebo
interve 4.18 (1.66)
ntion
No
interve 4.59 (2.02)
ntions
Pairwis
e
Difference
compar
ison

2.32-3.50

0.001

3.60-4.76
3.88-5.29

p-Value

Mean
95%CIb
SDa

1.681
1.26-2.10
.20

<0.001

0.410
0.07-0.76
.99

0.025

Topical
interventi
on
compare
d to no
interventi
ons
Placebo
interventi
on
compare
d to no
interventi
on
Topical
interventi
on
compare
d to
placebo
interventi
on

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Subject: Hemodialysis; Hospitals; Analgesics; Studies; Intervention; Insect bites; Confidence
intervals; Nursing; Data collection; Growth rate; Marital status;
Identifier / keyword: Hemodialysis, Needle, Lavender, Pain
Publication title: Complementary Therapies in Medicine
Volume: 23
Issue: 3
Pages: 325-330
Publication year: 2015
Publication date: Jun 2015
Year: 2015
Publisher: Elsevier Limited
Place of publication: Kidlington
Country of publication: United States
Publication subject: Medical Sciences--Chiropractic, Homeopathy, Osteopathy, Alternative
Medicine
ISSN: 09652299
Source type: Scholarly Journals
Language of publication: English
Document type: Journal Article
DOI: http://dx.doi.org/10.1016/j.ctim.2015.03.001
ProQuest document ID: 1686089705
Document URL: https://search.proquest.com/docview/1686089705?accountid=170128
Copyright: Copyright Elsevier Limited Jun 2015
Last updated: 2015-06-10
Database: ProQuest Family Health

29 February 2016

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Bibliography
Citation style: APA 6th - American Psychological Association, 6th Edition
Ghods, A. A., Abforosh, N. H., Ghorbani, R., & Asgari, M. R. (2015). 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, 23(3),
325-330. doi:http://dx.doi.org/10.1016/j.ctim.2015.03.001

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