|Year : 2020 | Volume
| Issue : 1 | Page : 64-73
Effect of acupressure therapy on insomnia and dizziness among patients undergoing hemodialysis
Mona H Ibrahim, Zeinab M El-Sayed, Salwa H Abdelaziz
Department of Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
|Date of Submission||31-Aug-2020|
|Date of Decision||10-Sep-2020|
|Date of Acceptance||13-Sep-2020|
|Date of Web Publication||18-Nov-2020|
Mona H Ibrahim
Department of Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo
Source of Support: None, Conflict of Interest: None
Background Acupressure is a low-cost treatment that has potential as an insomnia and dizziness therapy, especially in patients on maintenance hemodialysis (HD). It helps to improve sleep, relieve stress and tension, relax muscles and joints, minimize headache, as well treat the symptoms of dizziness.
Aim The aim was to evaluate the effect of acupressure therapy on insomnia and dizziness among patients undergoing HD.
Patients and methods A quasiexperimental (time series design) study was conducted. This study was conducted on the second floor of Nephrology–Dialysis–Transplantation Center at Kasr Al-Aini Hospital, affiliated with Cairo University. A nonprobability convenient consecutive sample of 88 adult male and female patients who have been on regular HD at least for 3 months was enrolled in this study. Three tools were used for data collection: first, Structured Interview Questionnaire regarding demographic and medical-related data; second, Insomnia Severity Index; and third, Dizziness Assessment Tool.
Results The study findings revealed that the mean age of the study and control group was 47.3±14.5 and 48.2±14.0 years, respectively. When analyzing insomnia level within three assessments at baseline and after 6 and 12 sessions, correspondingly, a significant difference was found between both groups, with higher reduction in the group that received acupressure (P=0.0001). Moreover, a statistically significant reduction of dizziness level in both groups was also observed, but a higher reduction was observed in the study group (P=0.02).
Conclusion Acupressure is effective in improving sleep and dizziness level among patients on HD.
Recommendation The study should be replicated on a larger probability sample, matched on the variable of sex.
Keywords: acupressure, dizziness, hemodialysis, insomnia
|How to cite this article:|
Ibrahim MH, El-Sayed ZM, Abdelaziz SH. Effect of acupressure therapy on insomnia and dizziness among patients undergoing hemodialysis. Egypt Nurs J 2020;17:64-73
|How to cite this URL:|
Ibrahim MH, El-Sayed ZM, Abdelaziz SH. Effect of acupressure therapy on insomnia and dizziness among patients undergoing hemodialysis. Egypt Nurs J [serial online] 2020 [cited 2020 Dec 3];17:64-73. Available from: http://www.enj.eg.net/text.asp?2020/17/1/64/300784
| Introduction|| |
Chronic renal failure (CRF) is one of the main worldwide health problems. In the USA, it is estimated that in the next years, the prevalence of CRF will increase, and more than two million persons are expected to receive renal replacement therapy by 2030. CRF induces a slow and progressive decline of kidney function. In fact, in CRF, there is a steady and continued decrease in renal clearance or glomerular filtration rate, which leads to the accumulation of urea, creatinine, and other chemicals in the blood that may lead to serious complications; hence, these patients require a long treatment in the form of renal replacement therapy (Amin et al., 2014).
Hemodialysis (HD) is one of the practical and safe methods of renal replacement therapy, as it alleviates symptoms by removing urea, creatinine, and free water from the blood. Although, HD is the most common methods to treat renal failure, the patients undergoing HD still have a wide range of problems and complications such as itching, nausea, vomiting, hypotension, dizziness, and sleep disorders (Shim and Cho, 2017).
Insomnia is considered the major sleep disorder among patients on HD. It is defined as the subjective sensation characterized by one or more of the following symptoms: difficulty falling asleep (sleep onset insomnia), difficulty staying asleep (sleep maintenance insomnia), early morning awakening, or poor sleep quality (nonrestorative sleep). In most cases, the diagnosis of insomnia is based on the presence of these symptoms at least for three to four times a week for several weeks (Hamzi et al., 2017). One of the short-term consequences of insomnia is dizziness which is a term used to describe a range of nonspecific sensation of disorientation, such as feeling light headed, faint, woozy, and weak or unsteady. The severities of dizziness and sleep-related problems are closely related to each other (Kim et al., 2018).
Insomnia and dizziness can be treated by pharmacological or nonpharmacological therapies. Acupressure therapy is the fifth most commonly used technique in complementary health approaches. It is a treatment modality in traditional Chinese medicine and a noninvasive variant of acupuncture form (Yeung et al., 2018). It is based on stimulation of meridians (a network of energy pathways throughout the body) to increase the flow of energy, subsequently altering the experience of symptoms. Moreover, it helps to relieve stress and tension, relax muscles and joints, improve sleep, alleviate chronic pain, minimize headache, as well treat the symptoms of dizziness by restoring the balance of the energy flow in the body. Hence, it is rapidly gaining acceptance as a safe, cost-effective, noninvasive, and nonpharmacological form of therapy (Carotenuto et al., 2013; Mehta et al., 2017).
Nurse in dialysis unit considers as one of the multidisciplinary team members who plays a significant role in reducing insomnia and dizziness levels among patients on HD by assessing the sleep pattern and quality (sufficient duration; appropriate timing; regularity and absences of sleep disturbance) also, by assessing activity, rest and blood circulation as dizziness indicators (Taha and Ali, 2015). Actually, it is vital that the nurses pinpoint the factors that may adversely affect the pattern and quality of sleep for those patients and develop plans to reduce their sleep disorders. Moreover, the nurses should be aware of nonpharmacological therapy such as acupressure to provide proper intervention. Therefore, the aim of the current study was to evaluate the effect of acupressure therapy on insomnia and dizziness among patients undergoing HD.
Significance of the study
End-stage renal disease is one of the main health problems, and its incidence is growing and is significantly increased in the developing countries such as Egypt (Soliman et al., 2012). In Egypt, the estimated annual incidence of end-stage renal disease is around 74 per million, and the total prevalence of patients on dialysis is 264 per million (El-Arbagy et al., 2016). At Kasr Al-Aini Hospital, the number of admitted patients having renal failure was 4880, 5230, and 5560 patients in 2017, 2018, and 2019, respectively. Currently, the Nephrology–Dialysis–Transplantation Center is serving 176 patients (Kasr Al-Aini Hospital Medical Records and Statistics Department, Cairo University, 2019).Scan research studies were conducted aiming to evaluate the effectiveness of acupressure therapy on insomnia and dizziness among patients undergoing HD. Moreover, during the investigators’ clinical experience, these patients verbalized feelings of despair resulting from insomnia in the form of fatigue, irritability, difficulty in concentration and decreased ability to perform activity of daily living, whereas dizziness is experienced in the form of light headed, feeling faint, and drowsiness.
Therefore, this study will build upon the science of complementary therapy, which may be useful to nursing and other health care professionals to decrease distress of insomnia and dizziness as well as optimizing quality of care for this group of patients. In addition, it is hoped that the findings of the current study will increase nurses’ knowledge related to nonpharmacological management of insomnia and dizziness for patients on HD, which may reflect positively on patient care and economic issues. Moreover, it is hoped that this effort might generate attention and motivation for further researches in this area of complementary therapy and establish evidence-based data that can promote nursing practice and research.
H1. Patients on HD who receive acupressure therapy will have lower mean insomnia scores than patients on HD who receive routine hospital care.
H2. Patients on HD who receive acupressure therapy will have lower mean dizziness scores than patients on HD who receive routine hospital care.
| Patients and methods|| |
Aim of the study
The aim of this study was to evaluate the effect of acupressure therapy on insomnia and dizziness among patients undergoing HD.
A quasiexperimental design (time series design) was used in this study to estimate the causal effect of acupressure therapy on its target population without random assignment. This design considers collection of observations sequentially through time (Chatfield, 2016).
The study was conducted on the second floor of Nephrology–Dialysis–Transplantation Center at Kasr Al-Aini Hospital, affiliated with Cairo University Hospital.
A nonprobability convenient consecutive sample of 88 adult male and female patients who have been on regular HD at least for 3 months and are able to communicate verbally constituted the study sample. The sample was equally divided into study and control groups. Patients with pacemaker, congestive heart failure, cancer, vestibular system disorders, or suffering from itching and redness on the prospect pressure points were excluded. The sample size calculated using a G-power version 3.1.1 (Cairo, Egypt) for power analysis. A power of 0.95 (β=1−0.95=0.05) at α 0.05 (one-sided tail) and the significance level of P less than or equal to 0.05 were utilized.
To achieve the aim of this study, three tools were used to collect data relevant to the study variables as follows:
Tool 1 was the Structured Interview Questionnaire. It was developed by the investigators. It includes two parts: first, demographic data covering questions related to age, sex, level of education, occupation, marital status, etc.; second, medical-related data such as duration of illness and history of chronic disease. Tool 2 was the Adopted Insomnia Severity Index (ISI), which was originally developed by Charles and Morin, 2003 (Morin et al., 2011). The ISI consists of seven questions concerning sleep onset, sleep maintenance, early awakening, level of satisfaction with sleep pattern, extent of interference with daily functioning, result of impairment caused by sleep problems, and level of concern about these problems. Each item is scored on a five-point Likert scale (0–4). Total score ranged from 0 to 28. Scores from 0 to 7 indicate no clinically significant insomnia, 8–14 subthreshold insomnia (mild), 15–21 clinically significant insomnia (moderate), and 22–28 clinically significant insomnia (severe), with test–retest reliability of r=0.84 (Morin et al., 2011). Tool 3 was the Dizziness Assessment Tool. This scale was developed by the investigator to assess dizziness levels and consists of 15 questions. Each item is scored on a 10-point Likert scale (0–10). Total score ranged from 0 to 150. Scores 0 indicate no clinically significant dizziness, 1–50 subthreshold dizziness (mild), 51–100 clinically significant dizziness (moderate), and 101–150 clinically significant dizziness (severe), with test–retest reliability of r=0.81. The validity of tools was done by a panel of five experts from Medical Surgical Department at Faculty of Nursing, Cairo University.
The approval to conduct the proposed study was obtained from the Research and Ethics Committees at Faculty of Nursing, Cairo University (IRB 00004025). Moreover, an official permission was obtained from the administrators of hospital/clinic where the study was conducted. Each patient was informed about the nature and purpose of the study as well as risks and benefits involved. The investigator emphasized that participation in the study is completely voluntary and participants can withdraw from the study at any time without effect on the medical care they receive. Then, those who choose to participate in the study were asked to sign the consent form. Additionally, confidentiality and anonymity were assured through coding the data.
The current study was conducted through the following dynamic three phases: preparatory, implementation, and evaluation. The preparatory phase includes thorough review of literature related to managing patients on HD as well as the uses of nonpharmacological therapy with a focus on acupressure, in addition to searching for the availability of the tools. During this phase also, the investigator developed Dizziness Assessment Tool, and all necessary steps for brochure preparation were carried out during this phase as well. This phase took nearly 4.5 months. Furthermore, during this phase, the investigator attended acupressure therapy course for 3 months in Acupressure Therapy Center in Egypt. The implementation phase is initiated once official permission is granted to proceed with the proposed study. The investigator initiated collecting demographic and medical-related data using tool 1, which was followed by filling out tools number 2 and 3 to assess initial level of insomnia and dizziness among the patients under the study. Then after that, in brief the investigator explained individually the content of the brochure to the participants in the study group to ensure their full cooperation.
After that, the investigator began to apply acupressure technique to the study group participants at the rate of three sessions per week for 1 full month for each patient in the study group according to Traditional Chinese Medicine Protocol on eight points at the right and left side of the body, which are Yintang (EX 2), Yifeng (SJ17 sanyinjiao), Anmian (EX22), Fengchi (GB20), and Hegu (LI4). The pressure for each point took one minute divided as follows: 30 s for pressure, 14 s to apply circular motion clockwise, 14 s counterclockwise, and 2 s for rest for this point; the time was calculated using stop watch. This technique was repeated for three times for each point; therefore, the total time of pressure for each point was three minutes and the total time for each patient was 24 min. In relation to the control group participants, they were receiving routine hospital care in this period. In the evaluation phase, two follow-up assessments were done for both groups upon completion of 6 and 12 sessions from initial assessment, respectively. These two assessments were done through filling ISI tool 2 and Dizziness Assessment Tool (tool 3). This phase took nearly 6 months. To apply the principle of fairness, the brochure was explained for participants in the control group by the investigator upon completion of the study.
Obtained data were tabulated, computed, and analyzed using Statistical Package for the Social Sciences version 23 (Cairo, Egypt). Descriptive statistics such as frequency, percentage, mean and SD, in addition to, inferential statistics including Paired t-test, analysis of variance (ANOVA)and χ2 test were utilized to analyze data pertinent to the study. Level of probability errors was adopted at P less than or equal to 0.05.
| Results|| |
The results were presented into three sections. Section I describes comparative description among the study and control groups on demographic and medical-related data ([Table 1],[Table 2],[Table 3]). Section II represents statistical analysis for research hypotheses among the study and control groups ([Table 4] and [Table 5]). Section III explains additional and correlation findings between insomnia and dizziness by using paired t-test, ANOVA, and Pearson correlation coefficient ([Table 6] and [Table 7]).
|Table 1 Comparative description among the study and control groups on demographic data (N=88, 44/each)|
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|Table 2 Comparative description among the study and control groups on medical-related data (N=88, 44/each)|
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|Table 3 Comparative description for current medications among the study and control groups (N=88, 44/each)|
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|Table 4 Frequency and percentage distribution of insomnia levels among the study and control groups at baseline, after 6 sessions, and after 12 sessions (N=88, 44/each)|
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|Table 5 Frequency and percentage distribution of dizziness levels among the study and control groups at baseline, after 6 sessions, and after 12 sessions (N=88, 44/each)|
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|Table 6 Comparison of mean scores related to different insomnia and dizziness assessments among the study and control groups (N=88, 44/each)|
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|Table 7 Correlation between insomnia and dizziness among the study and control groups using Pearson correlation coefficient (N=88, 44/each)|
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[Table 1] revealed that the age of 45.5 and 50% of the study and control groups, respectively, ranged between 40 and less than 60 years, with mean age of 47.3±14.5 and 48.2±14.0 years. Almost 72.7% of the study group represented female compared with 56.8% of the control group being male. Actually, a significant difference (P=0.004) was found to exist between the study and control groups on the variable of sex. The similarity of occupation among participants in both groups is apparent, as 86.4% of the study group and 88.6% of the control group were not working. The table showed also that 29.5% of study group and 22.7% of control group had secondary education level, respectively, in addition, 52.2% and 77.3% of the study and control groups, respectively, were married.
[Table 2] clarified that 77.3% of the study group and 70.5% of the control group were suffering from different chronic associated diseases, especially hypertension, which represent 40.9 and 43.2%, respectively. Concerning the number of hours of sleep at night, 79.5 and 81.8% among both groups reported that they slept 6 h/night though interrupted. In addition, 70.5 and 88.6% of the study and control groups, respectively, did not take nap time, and also, there was a significant difference between the study and control groups in relation to nap time (P=0.052).
As seen in [Table 3], there was no significant difference between the study and control group on the variable of the medication received and its dose (χ2=2.48, P=0.11), where 81.0, 66.7, 61.9, and 52.4% of study group receiving Calcimate, Norvasc, vitamin B complex, folic acid, and Eprex, respectively, whereas, 80.0, 80, and 40.0% of the control group receiving Eprex, Vit B complex, and Calcimate, respectively.
Regarding insomnia level, [Table 4] illustrated that there was a highly significant difference between study and control groups in relation to insomnia level (χ2=28.7, P=0.0001). Therefore, the first hypothesis of this study was supported.
Concerning dizziness level, [Table 5] shows that there was a significant difference between study and control groups in relation to dizziness level (χ2=7.3 and P=0.02). Therefore, the second hypothesis of the current study was supported.
[Table 6] clarifies that there was a highly significant difference between baseline and first assessment, baseline and second assessment, and first and second assessment mean scores regarding insomnia levels as follows: t=8.12, 23.7, and 16.7, respectively, at P=0.0001 among the study group, with ANOVA=2.74 at P=0.008. Also, there was significant difference only between baseline and second insomnia assessments mean scores among the control group as t=2.3, at P=0.02, with ANOVA at P=0.9. In reference to dizziness levels, the table disclosed that there was a highly significance difference between baseline and first assessment, baseline and second assessment, and first and second assessment mean score, as t=9.6, 18.4, and 12.9 at P=0.0001 among the study group, with ANOVA=1.45 at P=0.18. However, there was no significance difference between the three different assessments mean scores among the control group as t=1.3 at P=0.18, with ANOVA at P=0.7.
It is clear from [Table 7] that there was a strong positive association between insomnia and dizziness levels among the study and control group participants, which indicates the reciprocal relation between sleep and dizziness levels (r=0.55, P=0.0001 and r=0.56, P=0.0001, respectively).
| Discussion|| |
Insomnia and dizziness are among the most important health problems worldwide facing patients on HD with significance physical, psychological, and economic effects (Shim and Cho, 2017). On the contrary, acupressure is one of the nonpharmacological therapies used to improve patient sleep and decrease dizziness symptoms for patients on HD. The following discussion will concentrate upon the findings and interpretations related to the study findings.
The current study findings revealed that, approximately half of study and control groups had an age ranged between 40 and 60 years, with a mean of 47.3±14.5 and 48.2±14.0, respectively. This finding is consistent with Hamzi et al. (2017), as they conduct a study related to ‘Insomnia in HD patients’ on 125 patients and found that the studied participants mean age was 54.3±13.2 years; however, in a study carried out by Allah et al. (2014), on 107 patients observed that the mean age among the studied participants was 66.8±5.0 years. The age differences among the three research studies could be explained in the light of Centers for Disease Control and Prevention (2019), report, which stated that chronic kidney disease can develop at any age but becomes more common with increasing age, as after the age of 40 years, kidney filtration begins to fall by ∼1% per year (Amin et al., 2014).
Regarding sex, this study findings revealed that there are statistically significant differences between the two groups. More than two-thirds of the study group were female in comparison with more than half of the control group were male. This finding is incongruent with Samavat et al. (2017), as they mentioned that more than half of the study sample in their study was male. Moreover, a study carried out by Menezes et al. (2018) titled ‘Restless-legs syndrome in Dialysis Patients’ clarified that more than half of the study sample participants were male. On the contrary, Arache et al. (2019), assessed poor quality of sleep in 52 patients on chronic HD and reported that the male: female ratio was 1.1. However, Centers for Disease Control and Prevention (2019) clarified that CKD is more common in women (15%) than men (12%). From the investigators’ point of view, the sampling technique utilized in this study may explain these differences. The use of convenient sample may have been factor in this finding.
In relation to marital status, the current study displayed that most studied participants were married, which is expected among this age group in this culture. This finding is supported by Kumar and Sagar (2019), as they reported that the majority of their studied participants were married. Concerning educational level, this study documented that the majority of the participants fall into the literate category (secondary education). This finding is in agreement with Kumar and Sagar (2019) in India, as they mentioned that, the majority of their studied participants were literate. Nevertheless, the finding is inconsistent with a study carried by NoroziFiroz et al. (2019) in Iran, as they observed that around half of their studied participants were illiterate. This discrepancy could be interpreted by the facts that the majority of participants in the current study were from urban areas that places high value on education.
The current study findings showed that more than half of the participants were unemployed. This finding is consistent with Bhaskar et al. (2016), as they carried out a study entitled ‘Prevalence of chronic insomnia in adult patients and its correlation with medical co-morbidities’ on 278 patients and reported that more than one-third of the studied participants were unemployed. Many other research studies supported this finding. They all explained it in the light of the predominant symptoms of HD, which affect negatively person’s ability to work as well as the duration and the repetition of HD sessions. Therefore, no work can withstand this situation.
In reference to place of residence, this study illustrated that the majority of the study participants came from urban areas. This finding matched with the study by Allah et al. (2014), which was done in Zagazig City, Egypt. This finding could be explained by the fact that, the great majority of Egyptians, estimated 80 million people, live near the banks of the Nile River, where arable land is found. Another possible explanation that might partially account for this finding is the prevalence of chronic glomerulonephritis, renal calculi, and schistosomiasis, which are positively associated with the onset CKD (Ghonemy et al., 2016). Yet, this finding is incongruent with study conducted in India by Aggarwal et al. (2017); geographical distribution of the population in different countries might account for the differences in the study findings.
This study reported that almost half of the study and control group participants had hypertension, followed by diabetes. Similar findings concerning hypertension were also expressed by Yildiz et al. (2016). Another study conducted by Bhaskar et al. (2016) indicated that higher percentage had diabetes. These returns could be interpreted by the fact that diabetes and hypertension are significantly associated with the impairment of renal function, particularly among younger age with hypertension (Yuejuan et al., 2017).
The first study hypothesis stated that ‘Patients on hemodialysis who will receive acupressure therapy will have lower mean insomnia scores than patients on HD who receive routine hospital care’. Assessing the incidence of insomnia using the ISI questionnaire revealed that studied patients on HD in both groups experienced insomnia at the baseline assessment. This is supported by Hamzi et al. (2017), as they documented high prevalence of clinically significant insomnia among patients on HD. However, the level of insomnia was improved among the study group after completing six acupressure sessions as indicated by patients expressing satisfaction with their sleep pattern and decrease rate of insomnia severity. Moreover, this improvement continued until the 12 acupressure sessions that, the patients were very satisfied with their sleep pattern and had significant improvement in their quality of life and performing daily functioning.
On the contrary, there was no observable improvement of insomnia level among control group participants − receiving routine hospital care − from baseline assessment till the final assessment; after 4 weeks. That, the majority of control group participants continued to have moderate insomnia from baseline forward. Additionally, there was a high significant difference between study and control group in relation to insomnia level (χ2=28.7, P=0.0001). This finding could be explained by Nurul et al. (2018), as they conveyed that acupressure improve sleep quality of patient on HD by releasing the neurological mediators to physical process; relaxes the muscles and encourages the body to relax, helps in releasing neuro-transmitter and serotonin that plays important role in synthesizing melatonin, thus reduces insomnia and increases the desire of sleep. Subsequently, the patients on HD in the study group fall easily in sleep after acupressure sessions. Therefore, the first hypothesis of the current the study was supported.
The second study hypothesis stated that, ‘Patients on hemodialysis who will receive acupressure therapy will have lower mean dizziness scores than patients on hemodialysis who receive routine hospital care.’ Assessing the incidence of dizziness using Dizziness Assessment Tool revealed that studied patients on HD in both groups experienced dizziness at baseline assessment. This is supported by Hintistan and Deniz (2018), as they documented high prevalence of clinically significant dizziness in patients on HD. Though, it is worth mentioning that, the level of dizziness was improved after completing six acupressure sessions as indicated by patient expressing satisfaction with decreasing symptoms of dizziness as light headed, nausea, drowsiness, and feeling fainting. Moreover, this improvement continued until the 12 acupressure sessions, such that patients were very satisfied with their dizziness level and had significant improvement in their quality of life and performing daily functioning.
On the contrary, there was no noticeable improvement of dizziness level among control group participants − receiving routine hospital care − from baseline till the final assessment, that is, after 4 weeks, such that the majority of control group participants continued to have mild dizziness. Additionally, there was a highly significant difference between study and control group in relation to dizziness level (χ2=7.3, P=0.02). This finding could be explained by Arun and Venkateshan (2019), as they documented that acupressure decreases dizziness symptoms, repairs the energy flow, and relaxes the body’s organs. Therefore, the second hypothesis of the current the study was supported.
Concerning the relationship between insomnia and dizziness, the current study revealed that, there was a significant correlation between dizziness and insomnia among the study and control group participants (P=0.001). This finding is in agreement with Kim et al. (2018), as they conducted a study in Korea entitled ‘Relationship between sleep quality and dizziness’ and found that there was a strongly associations between sleep quality and dizziness. Therefore, it is important to consider sleep disturbance in patients on HD with dizziness and vice versa. Furthermore, findings depicted highly significant difference between study and control group participants in relation to the variables of sex and nap time. These differences may help in explaining the former finding and some other research findings.
Several possible factors may have relevance to the observed phenomena of the improved level of sleep and dizziness among the study group. One possible factor is patients’ accepting complementary alternative treatments owing to its low cost. Moreover, patients are searching for means to avoid adverse effects and complication of medicine, as well as out of despair from pharmacological management, as this might be the final and last mean to save them from the pain and discomfort they are constantly suffering from. Another important possible factor is the convenient sample that was utilized in the study.
| Conclusion|| |
The current study concluded that acupressure is effective in improving sleep and dizziness level among patients on HD.
Recommendations for future study
We recommend the following:
- Replication of the study using larger probability sample from different geographical areas in Egypt.
- Replication of the study matching participants on the variable of sex.
- Use variable instruments of acupressure to reach the maximum deep pressure for points.
The author grateful to God for the good health and well-being that were necessary to complete this work. The author gratitude to Dr Bassamat Omar Ahmed; Professor of Medical Surgical Nursing, Faculty of Nursing, Cairo University, who always gave much of her time, effort, guidance, suggestions, sincere advice, and tolerance throughout the progress of this work. The author wish to express deepest gratitude and appreciation to Dr Zeinab M. El-Sayed, and Dr Salwa Hagag Abdelaziz, Assistant Professor of Medical Surgical Nursing, Faculty of Nursing, for their support and advice, effort, guidance for the completion of this work.
Mona Hassan conducted the research, collect data, and prepared the primary draft; Dr Zeinab M. El-Sayed and Dr Salwa H. Abdelaziz analyzed and revised the data; all authors signed the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]