ne of the ailments that more than 50% of kidney patients report is experiencing some kind of pain. Hemodialysis requires two needles, arterial and venous. Patients undergoing annual hemodialysis experience pain from approximately 300 holes in their fistula. Pain relief is the basis of nursing care. Acupressure increases the level of endorphins in the blood, which is a type of internal morphine, and causes relaxation and reduces pain. One of the types of skin irritation methods is the stimulation of acupoints. Spleen Point 6 (SP6) or Sanyinjiao is one of the important acupoints. It is the branch of pelvic nerve activated from the preganglionic fibers in the T4-L5 region of the spine and located around the spleen canal. It is widely used for gynecological disorders, genitourinary disorders, gastrointestinal problems, weakness, hypotension, anesthesia during pelvic surgery and analgesia. Stomach 36 (ST36) or Zu San Li is another acupoint that is stimulated by different methods in acupressure. Stimulation of this point causes the secretion of serotonin, the reduction of sympathetic nerve activity, and the increase of endogenous opioids and has an analgesic effect. The aim of this study was to compare the effect of acupressure at SP6 and ST36 acupoints on the amount of pain caused by fistula needle placement in patients undergoing hemodialysis.

The present study is a double-blind randomized clinical trial. 90 samples were selected by a convenience sampling method, and then divided into two experimental groups of ST36 (n=30) and SP6 (n=30) and a control group (n=30) randomly and by using lottery method. Inclusion criteria were: age ≥15 years, full consciousness, having arteriovenous fistula, no smoking, having a minimum literacy, and not using analgesics 24 h before hemodialysis. Unwillingness to continue participation and the death of the patient were the criteria for exclusion from the study. After explaining the study purpose and methods to participants, a written informed consent was obtained from them. Data collection tools were a demographic form and the Visual Analog Scale (VAS). 
At the first session, a needle was inserted into the arteriovenous fistula of patients by a nurse, and the pain intensity was measured by the VAS. In the second session in the same week, acupressure massage was performed in two experimental groups at SP6 and ST36 acupoints in both legs, and immediately acupuncture was performed and the amount of pain was recorded again in both groups by the VAS. In the control group, no specific intervention was performed. To analyze the collected data, descriptive statistics and Chi-square test, Kolmogorov-Smirnov test, Kruskal-Wallis test, one-way ANOVA, and paired t-test were used in SPSS v. 16. The significance level was set at 0.05.

Findings of the study showed no statistically significant difference between the three groups in terms of pain score at baseline (P=0.081). ANCOVA results did not show a significant difference in pain score after the intervention between the three groups (P=0.309). Results of within- group comparison using paired t-test showed that the mean pain intensity in all three study groups was significantly different between pre-and post-intervention phases (P=0.02, P<0.001, and P=0.03 for SP6, ST36 and control groups, respectively). Comparison of mean differences in pain intensity before and after the intervention showed a statistically significant difference between the three groups (Table 1), and Tukey’s post hoc test results showed this difference between the control group and the intervention groups (P<0.001), while the two intervention groups were not significantly different from each other (P=0.759).

According to the research findings, massage of ST36 point and SP6 point is an effective method in relieving the pain caused by the needle entering the arteriovenous fistula and therefore it is recommended as a safe, simple and cheap solution.

The Ethics Committee of Gonabad University of Medical Sciences approved this study (Code: IR.GUMS.REC.1393.54). It has been registered by Iranian Registry of Clinical Trials (Code: IRCT2017102436747N1).

This study was received financial support from the Deputy for Research of Gonabad University of Medical Sciences.

All authors equally contributed to preparing this article.

The authors declareed no conflict of interest.

The authors would like to thank the Deputy for Research of Gonabad University of Medical Sciences, the staff of the dialysis department of 17 Shahrivar and Ghaem hospitals in Mashhad and all participants.