Effect of aromatherapy interventions on hemodialysis ...

Complementary Therapies in Clinical Practice 32 (2018) 130–138

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Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp

Effect of aromatherapy interventions on hemodialysis complications: A systematic review

T

Salehoddin Bouyaa, Sudabeh Ahmadidarehsimab, Mahin Badakhshc, Abbas Balouchid,e, Maryam koochakzaic,∗ a

Internal Medicine and Nephrology, Clinical Immunology Research Center, Ali-ebne Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran Faculty of Nursing and Midwifery, Jiroft University of Medical Sciences, Jiroft, Iran c Department of Midwifery, Faculty of Nursing and Midwifery, Zabol University of Medical Science, Zabol, Iran d Zabol University of Medical Sciences, Zabol, Iran e Student Research Committee, Nursing and Midwifery School, Iran University of Medical Sciences, Tehran, Iran b

A R T I C LE I N FO

A B S T R A C T

Keywords: Aromatherapy Hemodialysis complications Systematic review

Background and purpose: Aromatherapy, a CAM therapy, is a natural way of treating the mind, body and soul of individuals. The purpose of this study was to systematically review the literature to determine the effect of aromatherapy on hemodialysis complications. Methods: In this systematic review, international (PubMed, Google Scholar, Web of Science, CINHAL, EMBASE and Scopus) and national databases (SID and Magiran) were searched from inception of the databases to 30 December 2017. Results: The results showed that aromatherapy reduced some of the complications of hemodialysis, including anxiety, fatigue, pruritus, pain of arteriovenous fistula puncture, sleep quality, depression, stress and headache. In one case, it improved the quality of life of hemodialysis patients. Conclusion: Considering the complications and heavy costs of managing complications in patients undergoing hemodialysis, it appears that aromatherapy can be used as an inexpensive, fast-acting and effective treatment to reduce complications in hemodialysis patients.

1. Background Today, chronic kidney disease (CKD) is a widespread health problem, with more than 500 million people suffering from CKD globally [1]. Hemodialysis is the most important treatment for CKD as, of the 3 million people undergoing replacement renal treatment (RRT), 2.5 million (80%) use hemodialysis [2]. Hemodialysis has saved the lives of millions, but is associated with physical (fatigue, sleep disorders and pruritus) and psychological complications (depression, quality of life and anxiety) [3–5]. Complications of hemodialysis are treated using medications which are associated with adverse effects and, in the long run, cause dependence and exacerbation of disease-related complications [6,7]. Alternative treatments using complementary and alternative medicine (CAM) approaches have gained popularity in the last decade [8]. Aromatherapy, a CAM therapy, is a natural way of treating the mind, body and soul of individuals [9]. Aromatherapy is an inexpensive, popular and widely used method [10–12]. In aromatherapy, essential oils extracted from plants, flowers, fruits and the roots of the trees are used as the therapeutic agent [13]. ∗

Methods of using aromas include inhalation, massage, and simple use on the skin. Aromatherapy has been used to treat improve complications related to sleep quality and to reduce stress and anxiety. Aromatherapy results in the secretion of endorphins and noradrenaline by influencing the nervous system to create positive psychological and physical effects in the body. The major types of aromatherapy are: Cosmetic (used in hygiene products for skin, body and hair) [14]; Massage (with the use of oil) [15]; Medical (in clinical settings) [16]; Olfactory (inhalation to improve physical symptoms) [10]; Psycho-aromatherapy (to relieve psychological symptoms) [17]. Bergamot, lemon, lime, sweet orange and tangerine are all used in aromatherapy. In terms of safety, the aromas are usually safe and many are approved safe by the US FDA [18]. Individual studies have shown that aromatherapy can be used to treat fatigue, improve sleep quality and reduce anxiety in hemodialysis patients [17,19–22]. Hemodialysis complications impose high costs annually to the health system. Considering its lack of major complications, low cost, ease of use and beneficial effects, aromatherapy can be used to treat hemodialysis complications.

Corresponding author. Ferdowsi St, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran. E-mail addresses: [email protected], [email protected] (M. koochakzai).

https://doi.org/10.1016/j.ctcp.2018.06.008 Received 1 April 2018; Received in revised form 5 June 2018; Accepted 11 June 2018 1744-3881/ © 2018 Elsevier Ltd. All rights reserved.


S. Bouya et al.

2.4. Quality assessment and abstraction

According to the researchers' knowledge, no systematic review has been conducted to assess the effects of aromatherapy intervention on the complications of hemodialysis. The aim of this systematic review of experimental studies (clinical trials and quasi-experimental studies) was to assess the effect of different aromatherapy interventions (massage and inhalation aromatherapy) by using lavender, rosemary, rose water, peppermint oil, sunflower oil, chicory essence, tea tree oil, almond and jojoba oil aromas on hemodialysis complications including fatigue, stress, pain, depression, anxiety, sleep quality, pruritus, headache and quality of life in patients undergoing hemodialysis.

The quality assessment of the studies included was assessed using the Jadad scale whose rating criteria take into account randomization, double blinding, and withdrawals or dropouts. The scoring range in the Jadad scale goes from 0 to 5 in which a higher score represents higher quality of the study [25]. Table 1 The quality of quasi-experimental studies was assessed by JBI quasi-experimental appraisal tool [26].

2. Methods

3.1. Study selection

2.1. Registration and eligibility criteria

A total of 204 articles were retrieved from the initial search. Of the 119 non-duplicated studies in the title and abstract screening process, 71 were excluded because they had unrelated titles. Of the remaining 48 studies, 22 met the eligibility criteria. Of the 26 excluded studies, three were review articles, six used other type of CAM therapies, six were conducted on other populations, one was a letter to the editor, four did not have the complete text, four were not in either English or Persian and two did not meet quality requirements for inclusion (Fig. 1). Table 1 is a summary of the studies.

3. Results

The protocol of the present systematic review is registered in the Center for Reviews and Dissemination in PROSPERO (CRD42018092376). The methods adopted for this systematic review are consistent with the guidelines detailed on the PRISMA checklist [23]. All clinical trials (controlled or not) and semi-experimental clinical trials that investigated the effect of aromas (lavender, rosemary, rose water, peppermint oil, sunflower oil, chicory essence, tea tree oil, almond and jojoba oil) on the complications of hemodialysis patients administrated by massage and inhalation methods and assess complications (fatigue, stress, pain, depression, anxiety, sleep quality, pruritus, headache and quality of life) were included. Review studies, case reports, case series, letter to editors and descriptive studies were excluded. Target population was all hemodialysis patients undergone dialysis for more than six months.

3.2. Study characteristics The studies were conducted on 1087 hemodialysis patients having a mean age of 47 ± 14 (age range: 41.40–70.8 years). Most participants were female (n = 589; 54%). Of the 22 included studies, most (n = 16) used the RCT design. Most of the studies had a low risk of bias. and most (m = 16) were published in the English language (Table 1).

2.2. Search strategy The searches were conducted by two independent researchers following consultation with a health sciences librarian and an expert in CAM, who assisted in development of the overall search strategy and the identification of key MESH search terms and free terms according to PRESS standards [24]. The keywords used were: aromatherapy, inhalation aromatherapy, massage aromatherapy and hemodialysis complications. The electronic databases were searched from the inception of databases to December 30, 2017 and included international (CINHAL, PubMed, Scopus, EMBASE, ISI Web of Science and Google Scholar) and national databases (SID and Magiran), as well as the targeted publication journal (Complementary Therapies in Clinical Practice). Additional studies were identified by a manual search in proceedings from CAM conferences. Only complete papers available in English or Persian were included. To ensure literature saturation, the reference lists of the included studies were studied and relevant reviews were identified through the search. The MEDLINE strategy was first finalized, then adapted for search in other databases. PROSPERO was also searched for ongoing or recently completed systematic reviews.

3.3. Intervention The comparison groups used in the studies included no intervention or routine care (n = 6) [19,20,22,27–43] and placebo (n = 2) [21,44] groups. The identified methods for used for aromatherapy were inhalation (n = 6) [27,29,35,42–44] and massage (n = 16) [19–22,28,30–34,36–41]. Table 1 summarizes the details of the studies. 3.4. Selection of essential oils The essential oils used were either pure, diluted or a mixture of two or more essential oils at a particular ratio. The selection of essential oils used was determined by the aromatherapist, the effect on physical and physiological states and subject preference based on other studies. The most commonly used essential oils for massage and inhalation aromatherapy were lavender (n = 17) [19–22,28,30–33,35,37,39–44], orange (n = 3) and tea tree oil (n = 3) [33,35,38,40,42,43] (Table 1). 3.5. Administration protocol

2.3. Selection of studies and data extraction

The most common aromatherapy administration method was inhalation aromatherapy, used in more than 72% of the studies (n = 16) [19–22,28,30–34,36–38,40,41], and the most common frequency of use was three times a week (n = 17) [19–22,28–33,35,36,38,39,42–44].

Consistent with study protocol, the researchers independently screened the titles and abstracts for eligibility. The full text was then reviewed to confirm that the eligibility criteria were met and to extract the requisite information, which included the study characteristics (author, year, language, design, participants, gender, mean age and risk of bias), intervention details (comparison group, treatment group(s), type of aromatherapy, aromatherapy dose, treatment frequency, administration method, duration per session, total number of sessions and total duration of intervention) and measurements tools (main outcome, complications, scale, comparison group, type of aroma and results) were also collected. Duplicate studies were removed. Where a discrepancy existed between the researchers about inclusion of a study, discussions were held by the study authors to resolve the concerns through consensus.

3.5.1. Inhalation aromatherapy The aromatherapy doses were one to six drops, but the most frequent dose used was three drops [19,21,22,28,30–32,34,36]. The treatment frequency was every day to three days a week, but the most common frequency was three days a week [19–22,28,30–33,36,38,39]. The administration method differed between studies. In most, the method used for inhalation aromatherapy was by diluting the droplets and pouring the solution onto a cotton ball/handkerchief/gauze to be placed on the patient's collar at an appropriate distance (7–30 cm). The patient was then asked to breathe normally for a few minutes and the cotton ball was discarded. 131


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Fig. 1. Study selection process.

3.7. The effect of aromatherapy on hemodialysis complication

Inhalation aromatherapy was performed according to the requirements of the complication studied either during the day or at night before bedtime. The duration per session was 2 min to more than 10 h (one night), but the most frequent duration was 5 min [21,28,30,37]. The total number of sessions was three to 30 and the most common total number of sessions was 12 [19,20,22,31,32,38]. The total duration of intervention was one week to two months. The most common total duration was four weeks (n = 9) [19,20,22,31,32,34,38–40]. (Table 1).

3.7.1. Psychological effects

• Anxiety: Six studies evaluated the effect of aromatherapy on anxiety in

3.5.2. Massage aromatherapy The aromatherapy doses differed by study and ranged from one to three drops [27] of 0.1–5 ml [43,44], with three studies reporting no doses [29,35,42]. The treatment frequency was two [27] to three [29,35,42–44] days a week. The administration method differed. In most studies, the method used for massage aromatherapy was lubrication and massage by the researcher of the target area (non-fistulated hand, face, or palm) of the patient with oil combined with aromas for seven to 20 min. Massage aromatherapy was performed during dialysis in most studies. The duration per session was five to 25 min. The total duration of intervention was two to six weeks (Table 1).

•

•

3.6. Complications and measurement tools

•

The most commonly studied complications were anxiety (n = 6) [19,31,34,36,38,39], fatigue (n = 4) [21,32,33,40], pruritus (n = 4) [27,35,42,43], pain at arteriovenous fistula puncture (n = 3) [28,30,37], poor sleep quality (n = 4) [20,22,40,41], depression (n = 3) [19,31,36], stress (n = 2) [19,36], quality of life and headache (n = 1) [29,44]. The most frequently used instruments were VAS (n = 5) [21,28,30,40,44] and PSQI (n = 4) [20,22,40,41], followed by STAI (n = 3) [34,38,39] and PSS (n = 3) [35,42,43] [19,22]. Other assessment tools included SF-36 [29], HADS [31], MFI-20 [33] and BFI [21]. Table 1.

hemodialysis patients. All used inhalation aromatherapy. The aromas used included lavender, rose water, orange, and damask rose. Lavender aromatherapy had a positive effect on reducing anxiety in two studies [19,39] and had no effect on reducing anxiety in another study [31]. Rosewater, orange and damask rose aromatherapy reduced anxiety in patients undergoing hemodialysis [34,36,38]. Table 2 Depression: Three studies investigated the effect of aromatherapy on depression in hemodialysis patients. They all used inhalation aromatherapy. The aromas used were lavender and damask rose oils. The results indicated a positive effect for lavender and damask rose oils on the improvement of depression in hemodialysis patients [19,31,36]. Table 2 Stress: Two studies examined the effect of aromatherapy on stress in hemodialysis patients. They all used inhalation aromatherapy. The aromas used included lavender and damask rose oils. The results of the studies indicated a positive effect for lavender and damask rose oils on stress in hemodialysis patients [19,36]. Table 2 Quality of life: Only one study investigated the effect of aromatherapy on the quality of life of hemodialysis patients. This study used the massage aromatherapy method and the aroma used was chicory. The results indicated that chicory had a positive effect on improving the quality of life of patients undergoing hemodialysis [29]. Table 2

3.7.2. Physical effects

• Fatigue: 132

Four studies evaluated the effect of aromatherapy on

1.Pain of arteriovenous fistula puncture. 2.VAS 1.Anxiety, Depression 2. HADS

1.Clinical trial 2.80 3.4

1.RCT 2.92 3.3

1.RCT 2.72 3.3

Bagheri-Nesami, M. (2014) [30]

Bagheri-Nesami, M (2017) [31]

133

1.RCT 2.59 3.5

1.RCT (crossover) 2. 30 3.3

1.RCT 2.46 3.3

1.RCT 2.50 3.3

1.RCT 2.50 3.3

Bagheri-Nesami, M (2016) [32]

Balouchi, A. (2016) [33]

Barati, F. (2016) [34]

Bicer, S (2017) [21]

Biçer, S (2015) [44]

3 1 1

3 1 2

3 1 2

3 1 2

1.Fatigue 2. MFI-20

1.Anxiety 2.STAI

1.Fatigue 2.BFI/VAS

1.Headache 2.VAS

3

3 1 2

3 1 2

3 1 2

3. 1 2

1.Fatigue 2. FSS

1.Quality of Life 2. SF-36

1.Pain of arteriovenous. fistula puncture. 2.VAS

Atapour, A. (2016) [29]

Aliasgharpour, M. (2016) [28]

Aromatherapy consists of mix between two oils includes peppermint oil and sunflower oil Massage Aromatherapy, 1–2 drops, Twice a day, Topical 15–25 min/Six/Two weeks Aromatherapy with lavender essence 10% Inhalation Aromatherapy, 3 drops, three times a week, Inhalation Aromatherapy (three drops) of aromatherapy blend containing lavender essence 10% before needle insertion for 5 min from a distance of 7–10 cm. Five min/Six/Two weeks Chicory essence Massage aromatherapy, NR, three times a day, packages containing wet handkerchiefs scented with chicory essence and trained practically to clean their hands and faces thrice a day. Five min/87/Four weeks Essence was diluted 1:10 with sweet almond oil Inhalation Aromatherapy, 3 drops, three times a week, Inhaled lavender essence with a concentration of 10% for 5 min during 3 hemodialysis sessions Five min/Three/One week Aromatherapy with lavender essential oil Inhalation Aromatherapy, 3 drops, three times a week, a cotton ball infused with 3 drops of lavender essential oil 5% (diluted 1:20 with sweet almond oil) was attached to the patients' collar and they were then asked to breathe normally for 10 min. 10 min/12/Four weeks Aromatherapy with lavender essential oil Inhalation Aromatherapy, 3 drops, three times a week, a cotton ball soaked in 3 drops of lavender essential oil 5% (diluted 1:20 with sweet almond oil) was attached to each patient's collar and they were then asked to breathe slowly for 10 min. 10 min/12/Four weeks . lavender and sweet orange essential oil Inhalation Aromatherapy, one drop, three times a week, in each group, the patients were instructed to pour a drop of orange or lavender extract on a 2 × 2 cm gauze and pin the gauze to them shirt and rest the night after dialysis. One night/Six/Two weeks rose water Inhalation Aromatherapy, 3 drops, every night, put three drops of rose water (at a concentration of 25%) on a clean absorbent cotton handkerchief using a dropper each night before sleeping. 15–20 min/28/Four weeks lavender and rosemary Inhalation Aromatherapy, 3 drops, three times a week, 3 drops of lavender and rosemary oils were dripped in it and the patients were inhaled from an approximately 30-cm distance for 5 min. Five minutes/three/one week Lavender and rosemary Massage aromatherapy, 0.1 ml, three times a week Massage was performed in the first hour of each dialysis Session. 10 min/Nine/Three weeks

1. 2. 3. 1. 2.

1.Pruritus 2.5-D

1.Quasi-experimental (pretest-posttest)/2.30 3. Included 1.Quasi-experimental (pretest-posttest) 2.36 3.Included

Abdelghfar, S. Z (2017) [27]

Intervention 1. Treatment group(s) 2.Type, dose, frequency of Aromatherapy and Administration method 3.Duration per session/Total number of sessions/Total Duration of intervention

Study characteristics 1. Design 2. Sample 3. Quality assessment (Jadad or JBI scale)

First Author (Year)

Outcome and measurement

Table 1 Description of the study characteristics, outcome, measurement, interventions and results.

(continued on next page)

significant positive effect on headache

significant positive effect on fatigue

significant positive effect on anxiety

Orange had significant positive effect on fatigue Lavender had no significant positive effect on fatigue

No significant positive effect on fatigue

No significant positive effect on anxiety Significant positive effect on depression

Significant positive effect on pain

Significant positive effect on quality of life

Significant positive effect on pain of AVF puncture

Significant positive effect of Uremic Pruritus

Results

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1.Sleep quality 2.PSQI

1.Quasi-experimental (pretest-posttest) 2.53 3.Included

1.RCT 2.60 3.3

1.RCT 2.60 3.3

1. RCT 2. 34 3.3

1.RCT 2. 62 3.4

1.RCT 2.70 3.3

1.RCT 2.62 3.5

1.RCT 2. 60 3.4


Dabirian, Azam (2013) [20]

Dehkordi, A. K. (2016) [22]

Dehkordi, A. K. (2017) [36]

Ghods, A. A. (2014) [37]

Kanani, M (2012) [38]

134

Kiani, F. (2016) [39]

Muz, G. (2017) [40]

Najafi, Z. (2014) [41]

Ro, Y. (2002) [42]

1.Pruritus 2.PSS


1.Sleep quality and fatigue 2. PSQI, VAS and PFS

1.Anxiety 2.STAI

1.Anxiety 2.STAI

1.Pain of arteriovenous fistula puncture 2. NSR

1.Depression, anxiety and stress 2. DASS-21


1.Pruritus 2.PSS


Curcani, M. 2014 [35]

Outcome and measurement

Study characteristics 1. Design 2. Sample 3. Quality assessment (Jadad or JBI scale)

First Author (Year)

Table 1 (continued)

1 lavender, tea tree, almond and jojoba oils 2 Massage, Aromatherapy, NR, Three times a week, a six-week aromatherapy by the investigators during dialysis sessions three times a week for a period of 7–15 min for each region of the pruritus. 3 7–15 min/18/Six weeks 1 Lavender 2 Inhalation Aromatherapy, 2 drops, three times a week, at nights, before bedtime, they poured two drops of the essence on a cotton ball and placed in a small, non-plastic dish at a distance of 15–20 cm from the patients' pillow. 3 15–20 min/12/Four weeks 1 Lavender 2 Inhalation Aromatherapy, 3 drops, three times a week, a napkin was made wet with three drops of lavender and attached to the patient's collar; then, the patient was asked to breathe normally until the end of the dialysis session, when the napkin was separated. 3 3.5 h/12/Four weeks 1 Damask rose oil 2 Inhalation Aromatherapy, 3 drops, three times a week, Piece of cloth smeared with three drops of the damask rose oil with a constant density of 2% was attached to the patient's collar, and the patient was asked to breathe normally. 3 One hour/24/Two months 1 Lavender 2 Inhalation Aromatherapy, 6 drops, one time, six drops of essence were poured on 4 × 4 gauze and attached to the patient's collar 20 cm away from his/her nose. 3 Five min/NR/NR 1 Orange 2 Inhalation Aromatherapy, one drop, three times a week, one drop of Orange essence was poured on a handkerchief by a dropper and connected to the patient's collar with a pin and the patient was asked to breathe normally for 15–20 min. 3 15–20 min/12/Four weeks 1 Lavender 2 Inhalation Aromatherapy, two drops, two times a week, two drops of 5% lavender essence combined with sweet almond oil was poured by dropper on cotton and was attached by pin to patients ‘collar in addition to common cares of hemodialysis ward, and then they were asked `to breathe normally. 3 15–20 min/Eight/Four weeks 1 Sweet orange and lavender 2 Inhalation Aromatherapy, one drop Sweet orange and one drop lavender, every day, in practice, lavender and sweet orange oils (1:1) were dropped to a gauze bandage, which was placed 5 cm away from under the nose. 3 Two min/30/one month 1 Lavender 2 Inhalation Aromatherapy, two drops, every day, for 7 nights, the patient was exposed to two drops of lavender essence every night; the patient or his companion was asked to pure 2 drops of lavender essence, available in the dropper, on a pre-prepared cotton ball, and attach it with a pin to the patient's collar, separate it after awakening, and throw it away. 3 one night/Seven/one week 1 Lavender and tea tree 2 Massage Aromatherapy, NR, three times a week They received a 7-min massage on the upper and arm and the palm of the arm without fistula. 3 Seven min/12/Four weeks

Intervention 1. Treatment group(s) 2.Type, dose, frequency of Aromatherapy and Administration method 3.Duration per session/Total number of sessions/Total Duration of intervention

(continued on next page)

significant positive effect on Pruritus

significant positive effect on Sleep quality

significant positive effect on Sleep quality and Fatigue

significant positive effect on Anxiety

significant positive effect on Anxiety

significant positive effect on pain

significant positive effect on depression, anxiety and stress

significant positive effect on sleep quality

significant positive effect on sleep quality


Results

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1.Depression, Anxiety and Stress 2. DASS-21 1.RCT 2.58 3.4 Tayebi, Ali (2015) [19]

5-D: 5-D Itch Scale, VAS: Visual Analogue Scale, HADS: Hospital Anxiety and Depression Scale, FSS: Fatigue Severity Scale, MFI-20: Multidimensional Fatigue Inventory, STAI: State-Trait Anxiety Inventory, PSS: Pruritus Score Scale, PSQI: Pittsburgh Sleep Quality Index, DASS-21: Depression Anxiety Stress Scales, PFS: Piper Fatigue Scale, NRS: Numerical Rating Scale for pain, BFI: Brief Fatigue Inventory.


1 lavender, mint, and tea tree 2 Massage Aromatherapy, 3–5 ml, three times a week, All the participants received 7 min of hand massage in the non-fistulated hand with 3–5 ml of lavender, mint, and tea tree oils at 5% concentration for six sessions (two weeks). 3 Seven min/Six sessions/Two weeks. 1 Lavender 2 Inhalation Aromatherapy, three drops, three times a week, after attaching the patient to dialysis machine, a cloth wet with three drops of lavender standard essence was attached to the patient's collar and the patient was asked to breathe normally. 3. One hour/12 sessions/four weeks 1.Pruritus 2.PSS 1.Pre-Post clinical trial 2.24 3.Included Shahgholian, N. (2010) [43]

Significant positive effect on depression, anxiety and stress

Results Intervention 1. Treatment group(s) 2.Type, dose, frequency of Aromatherapy and Administration method 3.Duration per session/Total number of sessions/Total Duration of intervention Outcome and measurement Study characteristics 1. Design 2. Sample 3. Quality assessment (Jadad or JBI scale) First Author (Year)

Table 1 (continued)

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•

•

•

•

fatigue in patients undergoing hemodialysis. All of them used inhalation aromatherapy. The aromas used were lavender, rosemary and orange. Lavender had a positive effect on fatigue reducing fatigue in two studies [21,40], but not in the two other studies [32,33]. Rosemary and orange aromatherapy reduced fatigue in patients undergoing hemodialysis [21,33,40]. Table 2 Pruritus: Four studies examined the effect of aromatherapy on pruritus in hemodialysis patients. They all used massage aromatherapy. The aromas used were peppermint, almond, jojoba, mint, sunflower, lavender and tea tree oils. All of the aromas were found to have a positive effect on reducing pruritus in hemodialysis patients [27,35,42,43]. Table 2 Pain of arteriovenous fistula puncture: Three studies examined the effect of aromatherapy on pain of the arteriovenous fistula puncture in hemodialysis patients. They all used inhalation aromatherapy. The aroma used was lavender. The results indicated a positive effect for lavender on reducing the pain of the arteriovenous fistula puncture [28,30,37]. Table 2 Sleep quality: Three studies addressed the effect of aromatherapy on improving sleep quality in hemodialysis patients. They all used inhalation aromatherapy. The aroma used was lavender. The results of the studies indicated a positive effect for lavender on improving the sleep quality of patients undergoing hemodialysis [20,22,41]. Table 2 Headache: One study investigated the effect of aromatherapy on headaches in hemodialysis patients. This study used massage aromatherapy and the aromas used were rosemary and lavender. The results showed a positive effect for the use of rosemary and lavender on the headaches of hemodialysis patients [44]. Table 2

4. Discussion This systematic review was conducted to determine the effect of aromatherapy on hemodialysis complications from the inception of the databases to 30 December 2017. A review of the literature found 22 relevant studies conducted on 1087 hemodialysis patients. The most commonly used method was inhalation aromatherapy and the most common aroma used was lavender. Most studies have shown the beneficial effect of lavender on anxiety among patients undergoing hemodialysis. Studies on patients with heart failure in ICUs [45], postpartum mothers [46], patients in the preoperative period [47], preoperative breast surgery patients [48], dental patients [49] and students [50] also showed a positive effect for lavender on anxiety levels that similar of the results of studies on hemodialysis patients in current study. In contrast Muzzarelli [51] showed that lavender does not affect the anxiety of patients before colonoscopy that the different is may be due to larger sample size and patients physical and psychological conditions of included studies in current systematic review, most evidence suggests a beneficial effect of lavender on anxiety level. Rosewater and damask rose also had a positive effect on anxiety levels in hemodialysis patients. Other studies similarly have shown the efficacy of rose aromatherapy on intrapartum patients [52,53], students [54] and cardiac patients [55] that it should be due to overall effect of rosewater and damask rose on this complications. Lavender aromatherapy was shown to reduce fatigue in hemodialysis patients. Individual Studies on middle age women showed similar positive effects of aromatherapy on fatigue that it is may be due to same dose and frequency of aromatherapy sessions [56]. As well as Gok Metin Z study showed a positive effects of aromatherapy on fatigue in patients with rheumatoid arthritis which it is may be due to same design and total numbers of sessions of included studies in current study [57]. Orange and rosemary also were shown to reduce fatigue in patients undergoing hemodialysis. The results of a study on diabetic patients also show the positive effect of aromatherapy on fatigue [58]. This is should be due to chronic condition of disease in target populations in studies included in current study. 135


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Table 2 The effect of aromatherapy on hemodialysis complications. Hemodialysis complication

Type of aromatherapy

Therapeutic agent

Results

Anxiety

Inhalation Aromatherapy

Lavender


Rose water Orange Damask Rose Lavender

No significant positive effect [31] Significant positive effect [19] Significant positive effect [34] Significant positive effect [38] Significant positive effect [36] No Significant positive effect [32,33] Significant positive effect [21] Significant positive effect [33] Significant positive effect [21] Significant positive effect [27] Significant positive effect [27] Significant positive effect [35,42,43] Significant positive effect [35] Significant positive effect [43] Significant positive effect [28,30,37] Significant positive effect [20,22,41] Significant positive effect [19,31] Significant positive effect [36] Significant positive effect [19] Significant positive effect [36] Significant positive effect [29] Significant positive effect [44]

Fatigue

Pruritus

Massage Aromatherapy

Pain of arteriovenous fistula puncture Sleep quality Depression

Inhalation Aromatherapy Inhalation Aromatherapy Inhalation Aromatherapy

Stress


Quality of life Headache

Massage Aromatherapy Massage Aromatherapy

Orange Rosemary Peppermint oil Sunflower oil Lavender and tea tree oils Almond and jojoba oils Mint oils Lavender Lavender Lavender Damask rose oil Lavender Damask rose oil Chicory Rosemary and Lavender

5. Limitations

Studies have shown a beneficial effect for aromatherapy on reduction of pruritus in hemodialysis patients. Massage aromatherapy on women during delivery [59] also has shown decreased levels of pruritus it is should due to similar duration per session and design of study. In addition to reducing the amount of pruritus, massage aromatherapy also releases encephalin and freshens the skin [60]. Studies showed a beneficial effect for aromatherapy on pain relief of arteriovenous fistula puncture in hemodialysis patients. In agreement of current study, a systematic review has shown a positive effect of aromatherapy on acute and chronic pain [61], this is should be due to similar target population in some included studies, study design, frequency and method of aromatherapy, as well as a study conducted by Kamaran has shown similar positive effect on pain in peripheral venous cannulation pain this was may be due to same method of aromatherapy and duration per session [62]. Despite the present study, studies on pregnant women [63] showed no significant effect of aromatherapy on pain, which can be due to differences in target population, number of included studies, type and frequency of aromatherapy, and severity of pain. The studies showed a positive effect for aromatherapy on improvement of sleep quality in patients undergoing hemodialysis similar the Cho, Karadag and Moeini studies on cardiac patients in ICUs this is should be due to similarity in method of aromatherapy, duration per session, frequency of sessions, study design, used scale and type of used aroma [45,64,65]. Studies have demonstrated a positive effect of aromatherapy on depression in hemodialysis patients. In agreement of current a study conducted by Conrad shown a positive effect on depression of postpartum women [46], this is should be due to similar type of aroma and duration of aromatherapy per session. Studies have shown a positive effect for aromatherapy on stress in hemodialysis patients similar two systematic reviews which conducted by Kim and Hur Mh on middle-aged women and healthy adults, this was due to similarity in studies design, type of aromatherapy, and duration of aromatherapy [66,67]. The study that addressed quality of life showed a positive effect for aromatherapy on the quality of life in hemodialysis patients similar a systematic review conducted by Fung on elderly patients with dementia this was should be due to study design, and type of aromatherapies [68]. The only study found in this area indicated a positive effect of aromatherapy on a decrease in headaches in hemodialysis patients, in agreement of present results of a study that conducted by Cha on middle-aged women which shown a positive effect for aromatherapy on headache. [69], this was may be due to dose of aromatherapy and design of study.

The most important limitation of the present study was the variation in the aromas and doses used, which makes meta-analysis impossible for more accurate examination of the effect of the aromatherapy on hemodialysis complications. Another limitation was that some studies were published in languages other than English or Persian and were excluded from the present study due to lack of access to a skilled translator. 6. Strengths As far as the researchers could confirm, this is the first study that examines the effects of aromatherapy on hemodialysis patients. In this study, all studies in English and Persian were extracted that addressed all complications of hemodialysis patients without limitation. 7. Conclusion The results of the reviewed studies demonstrate the beneficial effect of inhalation and massage aromatherapy on the complications of fatigue, anxiety, stress, headache, pruritus and depression in hemodialysis patients. The results showed that aromatherapy improved the quality of life in hemodialysis patients. Considering the complications and heavy cost of managing complications in patients undergoing hemodialysis, it appears that aromatherapy can be used as an inexpensive, fast-acting and effective treatment to reduce the complications in hemodialysis patients subject to further study to assure the safety and effectiveness of the procedures. The results of included studies suggest that dialysis health care team can use different aromatherapy methods (massage and inhalation) by using an appropriate dose of beneficial aromas (lavender, rose water, orange and damask rose) as complementary therapies to reduce the different complications of dialysis (anxiety, fatigue, pruritus, pain of arteriovenous fistula puncture, sleep disturbances, depression, stress and headache) and improve the quality of life of hemodialysis patients as well as choice an appropriate dose and frequency of aromatherapy sessions in some complications due to limitation in number of studies required conducting more studies. Authors' contribution Salehoddin Bouya and Maryam koochakzai: study design and 136


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conceptualization; Sudabeh Ahmadidarehsima and Mahin Badakhsh: Search strategy and data collection; Abbas Balouchi and Maryam koochakzai: data analysis and interpretation; Salehoddin Bouya, Sudabeh Ahmadidarehsima, Mahin Badakhsh and Abbas Balouchi: manuscript writing; Salehoddin Bouya: study supervision.

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