original research

The Effect of Acupressure on the Level of Fatigue in Hemodialysis Patients

Rabiye Elence, RN, PhD; Nimet Karata, RN, PhD; Sultan Taci, RN, PhD

ABSTRACT Background Fatigue is one problem that is seen in high numbers in hemodialysis patients. Fatigue decreases quality of life by negatively affecting an individuals daily performance, activities, professional life, relations with family and friends, and treatment process. Objective This study was carried out to determine the effect of acupressure on the level of fatigue in hemodialysis patients. Methods/Design The study was conducted as experimental research with an acupressure (intervention) group and a control group. Setting The research, for which an ethics committees approval and institutional permission was obtained, was conducted in two central provinces of Turkey, Nevehir and Aksaray, at two hemodialysis centers with similar characteristics. Participants The research was completed with a total of 118 participants (52 in the intervention group and 66 in the control group) who met the inclusion criteria. Interventions A total of 12 acupressure sessions, 3 /wk for 1 mo, were performed for all participants in the intervention group, as required by the acupressureapplication protocol, applying acupressure at the

Stomach 36 (ST-36), Gallbladder 34 (GB-34), Spleen 6 (SP-6), and Kidney 1 (K-1) acupuncture points with a transcutaneous electrical nerve stimulation (TENS) acupuncture pen (XFT-320 acupuncture pen, Shenzhen Xunfegtong Electronics Co, Ltd, Shenzhen, China). Primary Outcome Measures A visual analog scale (VAS) for fatigue and the Piper Fatigue Scale (PFS) were used to evaluate the fatigue level of the participants before and after the acupressure application. Results After the acupressure applications for 1 mo, the subscale and total fatigue scores for the VAS (P < .001) and PFS were lower (P < .05) for participants in the intervention group compared to the controls, except for the cognitive subscale on the PFS (P < .05). Conclusions The study found that acupressure, applied using an acupuncture pen, was effective in decreasing fatigue in hemodialysis patients. Based on this result, the current research team suggests that hemodialysis patients and nurses should be informed about acupressure application so as to extend the use of acupressure in reducing fatigue symptoms. (Altern Ther Health Med. 2013;19(6):2331.)

Rabiye Elence, RN, PhD, is an assistant professor at Semra and Vefa Kk School of Health at the University of Nevsehir in Nevsehir, Turkey. Nimet Karata, RN, PhD, is a professor at Semra and Vefa Kk School of Health at the University of Nevsehir. Sultan Taci, RN, PhD, is an associate professor in the Department of Medical Nursing at the University of Erciyes in Kayseri, Turkey.

Corresponding author: Rabiye Elence, RN, PhD E-mail address: reglence@nevsehir.edu.tr

atigue is a problem with a high prevalence among patients receiving hemodialysis treatment due to the effects of end-stage renal disease (ESRD).1-3 Previous studies have reported that 71.0% to 92.2 % of patients experience fatigue4-6 and that fatigue is the most frequently observed condition in patients with chronic kidney disease (CKD).1-3,5,6 Fatigue is a common symptom in all chronic diseases and is defined using words like weakness, prostration, exhaustion, and ailment. It may have a negative effect on individuals daily performance, activities, professional life, relationships with family and friends, sex life, and course of treatment.7-11 In addition, fatigue increases individuals level of dependency and decreases their quality of life by reducing their physical capabilities.10
ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6 23

ElenceAcupressure, Fatigue, and Hemodialysis

Figure 1. XFT-320 TENS Device

Figure 2. XFT-320 TENS Device Specifications Name Model No. Power Supply Output Frequency Massage Pad Life Battery Life Size Electrical Stimulator XFT-320 DC 3.0 V (AAA/1.5Vx2) 1-1000 Hz 30-50 2-3 mo (30 min/d) 130 mm (L) 26 mm (W) 23 mm (H) Massage pad (2 pairs) Electrode wire (2 pieces) Acupuncture pen (1 pieces) Massage gel (1 piece) Battery (2 pieces)

Parts

Interventions that may enable patients to cope with fatigue include pharmacological and nonpharmacological methods. In chronic diseases, to increase individuals life expectancy and improve their quality of life, nurses and other members of the health team should act in unison and apply supplementary therapies for symptom control.11-13 Acupressure is one of these supplementary methods. Acupressure is a treatment method performed by applying pressure on acupuncture points by fingers, hands, or palms, or by using acustimulation devices to activate the bodys selfhealing power and to regulate energy flow.14-17 Although studies exist that show the efficacy of acupressure in the control of fatigue symptoms in ESRD patients,17-19 a literature review has not revealed any studies that demonstrate the effect of acupressure in the control of fatigue symptoms experienced by ESRD patients in Turkey. With new studies on the subject, acupressure application may be used as an independent nursing application in the control of fatigue symptoms experienced by hemodialysis patients. Materials and Methods This controlled, experimental research study was conducted to determine the effect of acupressure on the level of fatigue in patients receiving hemodialysis treatment. The acupressure was applied at the Stomach 36 (ST-36), Gallbladder 34 (GB-34), Spleen 6 (SP-6), and Kidney 1 (K-1) acupuncture points with a transcutaneous electrical nerve stimulation (TENS) acupuncture pen (XFT-320 acupuncture pen, Shenzhen Xunfegtong Electronics Co, Ltd, Shenzhen, China). See Figure 1 and Figure 2. Participants The required minimum sample size was determined to be 48 individuals for both the experimental and the control group, based on the calculation of = 0.05 and = 0.20, according to the results obtained by Shiow-Luan Tsay from the Piper Fatigue Scale (PFS).17 The research was completed with 52 participants in the intervention group and 66 participants in the control group (Figure 3). The power of the study was cal-

culated as 85%, taking the fatigue level into account. The study included participants who (1) were 18 years of age and older; (2) had been on hemodialysis for 3 months in hemodialysis units; (3) were receiving three hemodialysis sessions per week; (4) had obtained a visual analog scale (VAS) score of 3 or more for fatigue; (5) were not diagnosed with chronic, obstructive pulmonary disease, cancer, or psychiatric disease; (6) did not have a nerve, soft tissue, or venous disease or infection in lower extremities; (7) had not undergone any surgical operation; and (8) agreed to receive acupressure application. In all the centers where the research was conducted, no complementary-supplementary treatment was administered for the problems experienced by the participants, including fatigue, and they received only medical treatment. For this clinical study, formal approval was obtained from Erciyes Universitys Ethics Committee (No. 2009/93) and the study was conducted in compliance with the provisions of the Declaration of Helsinki (1995). Permission was obtained from the institutions in which the study was conducted, and written informed consent was obtained from the patients. Procedures The research was conducted in four hemodialysis centers in Nevehir Province and Aksaray Province. In Nevehir, two centers were included in the study. In Aksaray, initially three centers were to be included. One of the Aksaray centers, however, would not give the required permissions, and only two centers participated in the study. The study was performed with one intervention and one control group. The intervention group was composed of patients from the two hemodialysis centers in Nevehir Province. With the agreement from a biostatistician, participants for the control group were recruited from the hemodialysis centers in Aksaray because (1) the number of patients who met the inclusion criteria was inadequate in the centers in Nevehir, (2) the research team was unavailable to go daily to Aksaray and return back to Nevehir (distance of 75 km) to do the acupressure applications, (3) the researchers also

24

ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

ElenceAcupressure, Fatigue, and Hemodialysis

Figure 3. Sample Diagram Nevehir Province 145 patients Aksaray Province 210 patients

Excluded (n = 88) Not meeting inclusion criteria (n = 68) Declined to participate (n = 20)

Excluded (n = 141) Not meeting inclusion criteria (n = 107) Declined to participate (n = 34)

Intervention Group 57 patients were included in the study.

Control Group 69 patients were included in the study.

During the ongoing acupressure application: Three patients experienced different health problems: -Two patientsfistula problems -One patientcardiac problem Two patients did not want to continue because they slept during hemodialysis and did not want to be awoken for the acupressure application.

While the questionnaires were completed again at the end of mo 1 (follow-up): One patient did not want to continue; that is, they did not want to complete the questionnaires. Two patients moved to another city.

Intervention Group = 52 patients Completed on 10/15/2010

Control Group = 66 patients Completed on 07/30/2010

Analysis Analyzed (n = 52) Excluded from analysis (n = 0) had an educational responsibility, and (4) the sociocultural characteristics of patients in both provinces were similar. In this study, the research team ensured that the participants continued to receive their usual medical treatments in the course of the applications. To conduct the research in a well-organized way, the health care teams in the dialysis centers were informed about the objective and scope of the research. Intervention Group. During the first interview of the participants in the intervention group, the patient description form, VAS, and PFS were completed using face-to-face interviews and referring to participants records. Subsequently, for the intervention group, the investigator administered a
ElenceAcupressure, Fatigue, and Hemodialysis

Analyzed (n = 66) Excluded from analysis (n = 0) total of 12 acupressure applications, 3 times per week for the duration of 1 month, as required by the acupressure application protocol. This protocol was prepared in accordance with the literature.17-22 Acupressure was applied in the first half of each dialysis session (first 2 h), without too much water or electrolyte loss. No side effects associated with acupressure were observed during the applications. In the follow-up after the completion of the application at the end of 1 month, the VAS and the PFS were administered again, and the differences between participants baseline and final weights, blood pressure values, and laboratory findings were recorded (Figure 4).

ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

25

Figure 4. ProceduresParticipants in Intervention and Control Groups INTERVENTION GROUP Applications Obtaining oral and written consent from the participants Evaluating sociodemographic characteristics and disease-specific properties Evaluating laboratory findings and differences in entrance and exit weights and blood pressures Evaluating fatigueperforming VAS and PFS CONTROL GROUP Applications Obtaining oral and written consent from the participants Evaluating sociodemographic characteristics and disease-specific properties Evaluating laboratory findings and differences in entrance and exit weights and blood pressures Evaluating fatigueperforming VAS and PFS Performing no intervention Continuing routine treatment program

FIRST INTERVIEW

APPLICATION

FOLLOW-UP (1 mo later)

Performing acupressure application in 12 sessions, 3 /wk for 4 wks Continuing routine treatment program Evaluating laboratory findings and differences Evaluating laboratory findings and in entrance and exit weights and blood differences in entrance and exit weights and blood pressures pressures Evaluating fatigueperforming VAS and PFS Evaluating fatigueperforming VAS and PFS

Figure 5. Acupoints Selected for Treatment of Fatigue in the Study

Yanglingchuan (GB-34) Yungchuan (K-1) Zusanli (ST-36)

Sanyingjao (SP-6)

Control Group. In the first interview of the control participants, similar forms were completed as for the intervention group. No intervention was performed in the control group, and routine treatment programs were maintained. In the follow-up of the participants at the end of 1 month, the VAS and PFS were readministered, and differences between baseline and final weights, blood pressure values, and laboratory findings were recorded (Figure 4). Acupressure Treatment In this study, the investigator received 4 hours of applied training, from a physician who specialized in acupuncture, to learn how to locate the acupuncture points: ST36, GB34, SP6, and K1 (Figure 5). Two students studying in the depart26 ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

ment of nursing worked with the investigator (in turns) for the acupressure applications. The students working with the investigator were given a total of 8 hours of theoretical and applied training in acupressure application, and they were allowed to practice independently after they were observed to be able to perform each step of the procedure successfully. The TENS acupuncture pen used in the study is a bluntended and nonstinging device that has no features that require expertise and that can be self-administered by anyone. This device was used to perform massage and stimulate the acupuncture points. Massage strength could be adjusted between levels (modes) of 1 (weakest) to 10 (strongest). The treatment occurred in the first half of the hemodialysis sesElenceAcupressure, Fatigue, and Hemodialysis

Table 1. Acupressure Application Protocol 1. The acupuncture points were determined using the participants own fingers. Measuring correctly is important in acupressure application. The unit of measure is called cun (or tsun, sun, or chon) and is used to measure the distance from one acupressure point to another. The cun is roughly equivalent to 2.5 cm. The middle phalanges length when the width of thumb is twisted to middle finger is accepted as one cun. This should be measured with the individuals own fingers. The researcher measured between and determined acupressure points with patients fingers by holding her/his hands. 2. The determined points were established by marking them with a surgical pen with the participants consent. 3. The investigators positioned each participant in a seated posture that would ensure the participants comfort and privacy. In order to perform the acupressure application, clothes of the participants were rearranged and legs positioned until knees and legs were lying flat and the legs were accessible for treatment. Protecting privacy was important because the acupuncture procedure was done during a hemodialysis session. 4. Before application, a 5-min relaxation massage to the legs was performed with the effleurage technique. 5. A gel, which helped the electrode waves to transmit through the skin, was used to increase the sensitivity at the acupuncture points. 6. Before the actual treatment, the pens application was tested on an acupuncture point to determine if the participant felt mild vibrations/tingling. 7. The participant was told that it was enough to mildly feel the acupuncture pen when it was held on the acupressure point; the mode was changed until the participant first felt the vibrations. In that mode, the acupuncture pen was fixed to every point for 3 min. 8. The acupressure was applied symmetrically to the GB34, SP6, and K1 points, starting with the ST36 point and applying the pen on both legs at the same time (Figure 5). 9. The application was done during the first half of the hemodialysis session before too much fluid and electrolyte loss occurred and was performed 3 /wk for 4 wks. Acupressure application was performed on the participants by the researcher using an acupuncture pen. 10. Communication with the participant was sustained during the procedure. 11. At the end of the application, the gel was cleaned from the acupuncture points with cotton. 12. The participant was repositioned into a seated position. 13. The procedures were recorded in the nurses observation file.
ElenceAcupressure, Fatigue, and Hemodialysis

sions, which the participants received 3 times per week. Acupressure application was done based on a protocol developed by the current research team following the views of experts and information from a literature review (Table 1).17-22 The participant was told that it was enough to mildly feel the acupuncture pen when the investigator held it on the acupressure point. The mode was changed until the participant first felt the vibrations. In that mode, the acupuncture pen was applied for a total of 12 minutes, 3 minutes for each pointST36, GB34, SP6, and K1 (Figure 5). The TENS acupuncture pen was applied vertically on the skin, and gel was used to increase conductivity on the prespecified points on the skin. These applications are the same as indicated in the instructions for the device. The application was performed starting symmetrically from the ST36 point in the leg following a 5-minute effleurage, relaxing massage in the lower extremities. The investigator applied the pen to the same points on both legs at the same time. The investigators positioned participants in an appropriate posture that would ensure their privacy. In order to perform the acupressure application, clothes of the patients were rearranged until knees and legs were lying flat. Protecting privacy was important because the acupuncture procedure was done during a hemodialysis session. (Table 1) Therapeutic verbal communication was continued during the procedure to relax the participant. The procedure lasted 25 to 30 minutes. OUTCOME MEASURES Patient Description Form The patient description form, which was prepared by the investigator after a review of relevant literature, consisted of 23 questions that evaluated participants sociodemographic and disease characteristics and their laboratory results.1-3,5,6,17,18,23 VAS The VAS was developed by Price et al (1983).24 Several studies used it to evaluate the intensity of subjective pain perception and it was found to be reliable and valid.17,25,26 Many studies also used it to evaluate fatigue, which like pain is a subjective symptom. The numeric scale measures the severity of fatigue on a 10-cm horizontal line with two ends, where 0 = fatigue and 10 = worst fatigue. The value marked by the participant was taken as the fatigue severity value. The VAS was applied to participants before hemodialysis. The PFS was developed by Piper et al (1998) and consists of 22 items and evaluated individuals subjective perceptions of fatigue on four subdimensions.27 The scale also includes five additional items that were not used in the calculation of fatigue scores but were considered important in the assessment of data on fatigue. Responses for each item on the scale were assessed between 0 and 10 points. Subdimension scores were obtained by adding all points from the items in
ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6 27

PFS

Table 2. Sociodemographic Characteristics and Disease-specific Properties of Participants in Intervention and Control Groups Sociodemographic Characteristics and Disease-specific Properties Gender Female Male Educational status Illiterate Elementary school High school and higher Adherence to medical treatment Adhering Not adhering Adherence to diet therapy Adhering Partly adhering Not adhering Mean age Mean hemodialysis duration (mo) Hemoglobin (g/dL) Hematocrit (%) Kt/V Intervention (n = 52) No. 23 29 9 37 6 41 11 16 18 18 52.4 11.6 73.6 44.6 11.8 1.2 36.0 3.8 1.39 0.1 % 44.3 55.7 17.3 71.2 11.5 78.8 21.2 30.8 34.6 34.6 Groups Control (n = 66) No. 34 32 22 39 5 59 7 28 25 13 55.6 9.8 62.7 47.1 11.5 1.0 35.1 3.2 1.40 0.2 % 51.5 48.5 33.3 59.1 7.6 89.4 10.6 42.4 37.9 19.7 P Value .548

.136

.185

.165 .104 .204 .098 .153 .940

Abbreviations: Kt/V = measure of renal dialysis adequacy. a given subdimension and then dividing this sum by the number of items. Total fatigue score was obtained by adding the points from 22 subdimensions and then dividing this sum by the number of subdimensions. Higher scores obtained from the scale indicated higher levels of fatigue perception. The validity and reliability of the Turkish version of the scale was tested by Can (2001), and Cronbachs coefficient was determined to be 0.94.28 In the current study, Cronbachs coefficient of the scale was found to be 0.96 in the intervention group, 0.92 in the control group, and 0.94 overall. Statistical Analysis Data were evaluated using SPSS version 16.0 (SPSS Inc, Chicago, IL, USA) and SigmaStat 3.5 statistical software (Systat Software, San Jose, CA, USA). Normality of distribution of the data was assessed by the Shapiro-Wilk test. Two independent sample t tests and a dependent sample t test were used for variables with a normal distribution, and the Mann-Whitney U test, Wilcoxon signed-rank test, and Spearmans rank-order correlation were used for variables without a normal distribution. A 2 test was used in the com28 ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

parison of categorical variables. The value of P < .05 was accepted to be statistically significant. RESULTS The mean age of the individuals in the intervention group was 52.4 11.6; 55.7% were male, and 71.2% were primary school graduates. Individuals in the intervention group had been on hemodialysis for 73.6 44.6 months on average; 78.8% of that group had complied with their medications, and 69.2% partially or completely failed to comply with their diets (Table 2). The mean age of the individuals in the control group was 55.6 9.8; 51.5% were female and 59.1% were primary school graduates. Participants in the control group had been on hemodialysis for 62.7 47.1 months on average; 89.4% complied with their medication, and 57.6% partially or completely failed to comply with their diets. The intervention and control groups were comparable in terms of sociodemographic and medical characteristics, P > .05 (Table 2). The participants in the intervention group had been experiencing fatigue for 42.6 28.6 months on average. Of
ElenceAcupressure, Fatigue, and Hemodialysis

Table 3. Baseline Fatigue Characteristics of Intervention and Control Groups Groups Fatigue Characteristics Intervention (n = 52) No. % Control (n = 66) No. % P Value

Opinions about the cause of fatiguea Dialysis CRF Too much liquid Anemia Do not know Fatigue descriptions Weakness Exhaustion Prostration Ailment Unhappiness Average fatigue periodb (mo) 28 7 9 7 1 42.6 28.6 53.8 13.5 17.3 13.5 1.9 34 12 16 2 2 41.5 35.1 51.5 18.2 24.2 3.0 3.0 37 14 3 0 1 71.2 26.9 5.8 0 1.9 42 16 2 5 4 63.6 24.2 3.0 7.6 6.1

.250

.856

Applications performed to reduce fatiguea Resting Walking Paying attention to nutrition 50 5 0 96.2 9.6 0 63 6 2 95.5 9.1 3.0

Abbreviations: CRF = chronic renal failure; SD = standard deviation.

a b

More than one answer was given; therefore, the P value was not evaluated. Mean SD. the sensory subscale, 4.6 (3.5-6.6) in the cognitive/mental subscale, and 5.3 (4.3-7.4) overall. The total-score medians for all subscales, except for the cognitive/mental subscale (P > .05), and the total-score medians obtained from the PFS were lower compared to those obtained in the baseline, P < .05 (Table 4). For the control group in the follow-up, the median PFS scores were 7.6 (5.7-8.8) in the behavior/severity subscale, 8.0 (5.8-9.4) in the emotion subscale, 7.5 (5.2-8.8) in the sensory subscale, 5.9 (4.5-7.3) in the cognitive/mental subscale, and 7.2 (5.3-8.5) overall. The median scores on the emotion and cognitive/mental subscales and the total-score median obtained by these participants were higher compared to those obtained in the baseline. For the baseline and follow-up scores, the differences between the intervention and control groups in terms of the total-score medians and the median scores for all subscales of the PFS were statistically significant, P < .05 (Table 4).

that group, 53.8% described fatigue as weakness, 71.2% thought that hemodialysis treatment caused fatigue, and 96.2% mentioned that they took a rest to reduce their fatigue. The participants in the control group had been experiencing fatigue for 41.5 35.1 months on average. Some 51.5% of the participants in the control group described fatigue as weakness, 63.6% thought that hemodialysis treatment caused fatigue, and 95.5% mentioned that they took a rest to reduce their fatigue (Table 3). The current study found that the median VAS score in the intervention group decreased from 7.6 (5.0-10.0) in the baseline to 5.0 (4.0-7.2) in the follow-up, whereas for the participants in the control group, the median fatigue score increased from 6.7 (5.0-9.0) in the baseline to 8.0 (5.0-10.0) in the follow-up. The difference between the groups was statistically significant, P < .01 (Table 4). For the intervention group in the follow-up, the median PFS scores were 6.0 (4.7-7.8) in the behavior/severity subscale, 5.3 (4.6-8.3) in the emotion subscale, 5.3 (4.3-7.8) in
ElenceAcupressure, Fatigue, and Hemodialysis

ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

29

Table 4. Median VAS and PFS Scores of the Participants in the Intervention and Control Groups in Baseline and Follow-up Intervention Group Median (25%-75%) Fatigue Scale VAS PFS Behavior/severity subscale Emotion subscale Sensory subscale Cognitive/mental subscale Overall fatigue score 6.8 (5.2-8.2) (6.7 2.0)b 6.7 (5.0-8.9) 6.6 (4.8-8.3) 4.5 (3.0-6.6) (4.7 2.2)b 5.7 (4.9-8.0) 6.0 (4.7-7.8) (6.2 2.0)b 5.3 (4.6-8.3) 5.3 (4.3-7.8) (5.8 2.2)b 4.6 (3.5-6.6) (4.9 2.1)b 5.3 (4.3-7.4) (5.8 1.9)b .001 .001 .01 .136 .001 7.7(5.8-9.1) (7.3 1.9 )b 7.5 (5.6-9.0) 7.5 (5.2-8.2) 5.5 (4.2-7.1) (5.3 2.1)b 6.7 (5.2-8.1) 7.6 (5.7-8.8) (7.2 2.0)b 8.0 (5.8-9.4) 7.5 (5.2-8.8) (7.0 2.0)b 5.9 (4.5-7.3) (5.8 2.2)b 7.2 (5.3-8.5) (6.9 1.8)b .526 .459 .199 .021 .178 .126d .207c .384c .190d .198c .011d .002c .002d .022d .002d Baseline 7.6 (5.0-10) Follow-up 5.0 (4.0-7.2) Pa .001 Control Group Median (25%-75%) Baseline 6.7 (5.0-9.0) Follow-up 8.0 (5.0-10) Pa .069

P Values Baseline .251c Follow-up .001c

Note: Median (25%-75%) reflects range between 25th percentile and 75th percentile. Wilcoxon signed-rank test. Mean standard deviation. c Mann-Whitney U test. d Two independent sample t tests.
a b

DISCUSSION Fatigue is the most frequent symptom seen in participants with CKD and has a considerable effect on participants daily life activities and quality of life.1-3,5,6 It is possible to cope effectively with the symptom of fatigue by assessing it and planning appropriate interventions for the patient to prevent its negative effects. No known specific treatment for the symptom of fatigue exists. Pharmacological and nonpharmacological methods can be used for this purpose.8-12,29,30 Acupressure is one of the nonpharmacological methods.15,17-19 For the intervention and control groups in the current study, no statistically significant differences were found between the participants median VAS scores in the baseline (P > .05), whereas in the follow-up, participants median VAS scores decreased in the intervention group and increased in the control group. This difference between the groups was statistically significant, P < .01 (Table 4). In the follow-up of participants in the intervention group, a decrease was found in the overall median fatigue scores, and the median scores obtained from all subscales of the fatigue scale, except for the cognitive/mental subscale. On the other hand, in the control group, the overall median fatigue scores and the median scores from the cognitive/mental and emotion subscales were higher in the follow-up compared to baseline. The median score obtained from the sensory subscale remained unchanged, and the median score obtained from the behavior/ severity subscale decreased compared to baseline,
30 ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

P < .05 (Table 4). The current research considers that the positive effect of acupressure application on the reduction of fatigue may be associated with the physiological effect of direct application as well as with the psychological support given to the participants during the applications, which diverted their attention from their condition. The findings of this study are similar to those obtained from a limited number of studies in the literature that evaluated the effect of acupressure application on the level of fatigue in hemodialysis participants.17-19 Tsay conducted a study to determine the effect of acupressure on fatigue level in hemodialysis patients and reported that acupressure and placebo acupressure applications decreased fatigue; however, no statistically significant difference existed between the groups.17 Tsay also mentioned that the decrease in the level of fatigue achieved through placebo application could be a result of the relaxing effect of massage.17 Another study reported that finger acupressure and acupressure applied with a stimulation device decreased the level of fatigue in hemodialysis participants compared to the control group, and the mode of application did not create any change in the fatigue status.18 A study by Cho and Tsay found that acupressure application in hemodialysis participants decreased participants perception of fatigue.19 Zick et al, in a study conducted with cancer participants, reported a decrease in participants perception of fatigue at the end of the acupressure application.15
ElenceAcupressure, Fatigue, and Hemodialysis

CONCLUSIONS This study found that acupressure applied for 12 sessions with an TENS acupuncture pen to the ST36, GB34, SP6, and K1 acupuncture points in the leg and foot was effective in decreasing the level of fatigue in hemodialysis participants and that TENS acupressure application was an easy and economical, nonpharmacological method, without any side effects, that can be easily applied by nurses to hemodialysis participants suffering from fatigue.
AUTHOR DISCLOSURE STATEMENT

26. Dernis-Labous E, Messow M, Dougados M. Assessment of fatigue in the management of patients with ankylosing spondylitis. Rheumatology (Oxford) . 2003;42(12):1523-1528. 27. Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul SM. The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum. 1998;25(4):677-684. 28. Can G, Durna Z, Aydiner A. Assessment of fatigue in and care needs of Turkish women with breast cancer. Cancer Nurs. 2004;27(2):153-161. 29. Wagner LI, Cella D. Fatigue and cancer: causes, prevalence and treatment approaches. Br J Cancer. 2004;91(5):822-828. 30. Barnes EA, Bruera E. Fatigue in patients with advanced cancer: a review. Int J Gynecol Cancer. 2002;12(5):424-428.

This study was supported by the Scientific Research Projects Department of Erciyes University under the project No. TSD-10-3071, as a dissertation study. This paper was presented at the 13th National Congress of Internal Medicine-Nursing Section (5-9 October 2011, Antalya, Turkey).

REFERENCES

1. McCann K, Boore JR. Fatigue in persons with renal failure who require maintenance haemodialysis. J Adv Nurs. 2000;32(5):1132-1142. 2. OSullivan D, McCarthy G. Exploring the symptom of fatigue in patients with end stage renal disease. Nephrol Nurs J. 2009;36(1):37-47. 3. Liu HE. Fatigue and associated factors in hemodialysis patients in Taiwan. Res Nurs Health. 2006;29(1):40-50. 4. Murtagh FE, Addington-Hall J, Higginson IJ. The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis . 2007;14(1):82-99. 5. Williams AG, Crane PB, Kring D. Fatigue in African American women on hemodialysis. Nephrol Nurs J. 2007;34(6):610-618. 6. Yurtsever S, Bedk T. Hemodiyaliz hastalarnda yorgunluun deerlendirilmesi. Hemirelikte Aratrma Gelitirme Dergisi. 2003;2:3-12. 7. Swain MG. Fatigue in chronic disease. Clin Sci (Lond). 2000;99(1):1-8. 8. Stone P, Richards M, Hardy J. Fatigue in patients with cancer. Eur J Cancer. 1998;34(11):1670-1676. 9. Knowles G, Borthwick D, Mcamara S, Miller M, Leggot L. Survey of nurses assessment of cancer-related fatigue. Eur J Cancer Care (Engl). 2000;9(2):105113. 10. Wu HS, McSweeney M. Measurement of fatigue in people with cancer. Oncol Nurs Forum. 2001;28(9):1371-1384. 11. Mock V. Fatigue management: evidence and guidelines for practice. Cancer. 2001;92(6)(suppl):1699-1707. 12. Morrow GR, Shelke AR, Roscoe JA, Hickok JT, Mustian K. Management of cancer-related fatigue. Cancer Invest. 2005;23(3):229-239. 13. Filshie J. Safety aspects of acupuncture in palliative care. Acupunct Med . 2001;19(2):117-122. 14. Hakverdioglu G, Turk G. Acupressure. J Hacettepe Univ Sch Nurs. 2006;13(2): 43-47. 15. Zick SM, Alrawi S, Merel G, et al. Relaxation acupressure reduces persistent cancer-related fatigue. Evid Based Complement Alternat Med. 2011;2011. pii:142913. 16. Chen ML, Lin LC, Wu SC, Lin JG. The effectiveness of acupressure in improving the quality of sleep of institutionalized residents. J Gerontol A Biol Sci Med Sci. 1999;54(8):M389-M394. 17. Tsay SL. Acupressure and fatigue in patients with end-stage renal diseasea randomized controlled trial. Int J Nurs Stud. 2004;41(1):99-106. 18. Tsay SL, Cho YC, Chen ML. Acupressure and transcutaneous electrical acupoint stimulation in improving fatigue, sleep quality and depression in hemodialysis patients. Am J Chin Med. 2004;32(3):407-416. 19. Cho YC, Tsay SL. The effect of acupressure with massage on fatigue and depression in patients with end-stage renal disease. J Nurs Res. 2004;12(1):51-59. 20. Tsay SL, Rong JR, Lin PF. Acupoints massage in improving the quality of sleep and quality of life in patients with end-stage renal disease. J Adv Nurs . 2003;42(2):134-142. 21. Zhu LF, Pan XH, Zhou Z, Huang K. Effects of adjunctive acupressure for muscle cramps of lower extremities in patients undergoing hemodialysis. Mod J Int Trad Chinese Western Med. 2006;17:2347-2348. 22. Jedras M, Bataa O, Gellert R, et al. Acupressure in the treatment of uremic pruritus. Dial Transplant. 2003;32(1):8-10. 23. Kim HR, Son GR. Fatigue and its related factors in Korean patients on hemodialysis. Taehan Kanho Hakhoe Chi. 2005;35(4):701-708. 24. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain . 1983;17(1):45-56. 25. Pollard LC, Choy EH, Gonzalez J, Khoshaba B, Scot DL. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology (Oxford) . 2006;45(7):885-889.

Help Patients Find Balance

HELP STARTS HERE.

Hormone balance is deeply connected to our overall wellness. Hormones not only regulate our immune system and response to stress, but also help maintain libido and energy levels. Call 1-877-647-0322 today for world class hormone testing to identify treatable hormonal imbalances.
LABORATORY TESTING MADE SIMPLE
2013 ZRT Laboratory, LLC. All rights reserved.

ZRT Laboratory

www.zrtlab.com

x ElenceAcupressure, Fatigue, and Hemodialysis

ALTERNATIVE THERAPIES, NOV/DEC 2013, VOL. 19, 6

31

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.