Effect of Acupressure on Sleep Quality of

Hemodialysis Patients
PICO Question
Background: poor sleep quality has been known to be a frequent
problem in End Stage Renal Disease patients undergoing
hemodialysis. Studies on how to improve sleep quality in this
population had been done and acupressure is one of them. The
PICO question would be:

• Patient : Hemodialysis patients

• Intervention : Acupressure
• Outcome : Sleep quality
PICO Question
The complete question is:
“In adult patients undergoing hemodialysis, does
the apply of acupressure have any effect on their
sleep quality?”

An interventional question.
Best answered with: systematic review or meta-
analysis of randomized controlled trial.
Clinical Significant
Hemodialysis is the most common therapy used to treat End Stage
Renal Disease Patients (ESRD), with the number of new patients
increasing every year (NIDDK, 2006; Indonesia Renal Registry,
2014; KDOQI Clinical Practice Guideline For Hemodialysis
Adequacy: 2015 Update, 2015).

Patients on hemodialysis have many health problems. Complaints

about sleep quality are very common in patients who are undergoing
hemodialysis treatment. Poor sleep quality is among the top three
problems in hemodialysis population (Curtin, Bultman et al. 2002;
Weisbord, 2005).
Clinical Significant
Sleep plays an important role in humans’ life, getting good quality of
sleep will help maintaining mental and physical health, and improves
quality of life. Many studies reported that patients undergoing
hemodialysis are most likely to have poor sleep quality (Pai et al. 2007;
Trbojević-Stanković, Stojimirović et al. 2014; Ezzat and Mohab 2015;
Sekercioglu, Curtis, Murphy, & Barrett, 2015).

Continuous poor sleep quality will affect to the decrease in the quality
of life and increase in the mortality rate (Gusbeth-Tatomir, Boisteanu,
Seica, Buga, & Covic, 2007; Masoumi, 2015).
Search Strategies
Step 1 : Database search using keywords from
PICO question

Step 2 : Title reading

Step 3 : Exclusion of same articles and

applying the inclusion criteria
56 references were identified
PubMed=9 SD=39
CINAHL=3 Cochrane=5

9 references had proper title 48 references did not have either

PubMed=2 SD=1 acupressure, hemodialysis, or
CINAHL=2 Cochrane=4 sleep quality

5 references fit the criteria 4 references were excluded: no

PubMed=2 SD=1 full text, older than 10 years,
CINAHL=0 Cochrane=2 different kind of acupressure

2 references fixed 2 references were excluded

PubMed=1 SD=0 because of duplication
CINAHL=0 Cochrane=1
The References
• Arab, Z., Shariati, A., Asayesh, H., Vakili, M., Bahrami-
Taghanaki, H., & Azizi, H. (2015). A sham-controlled trial of
acupressure on the quality of sleep and life in haemodialysis
patients. Acupunct Med, 34(1), 2-6.
http://dx.doi.org/10.1136/acupmed-2014-010369

• Shariati, A., Jahani, S., Hooshmand, M., & Khalili, N. (2012).

The effect of acupressure on sleep quality in hemodialysis
patients. Complementary Therapies In Medicine, 20(6), 417-
423. http://dx.doi.org/10.1016/j.ctim.2012.08.001
 Research Findings
Auth Year Partici Age Study Interve Detail Topic and Activity Major Finding
or pant Design ntion

Arab 2015 Interve 18-70 RCT True The intervention group received A significant difference in the total
et al. ntion: years acupres acupressure in the bilateral Shenmen PSQI was observed between the
32 sure vs. points (HT7), three times a week for 4 three groups after the study
Placeb placebo weeks. A pressure equal to 3–4 kg was (p<0.001).
o: 30 acupres applied for 8 min with the thumb (3 min
Control sure vs. on each point with 2 min rest between) Using the Bonferroni correction
: 32 no using a circular movement at the rate of test, a significant difference in the
treatme two rotations per second, 1 h after total score was observed between
nt dialysis. the true acupressure and placebo
acupressure groups (p<0.001), and
The sham acupressure was performed on also between the true acupressure
points at 0.5 cm from the true points and and no treatment groups (p<0.001).
not on the traditional meridian pathways.
The third group received no treatment There was no difference between
other than routine daily care. the placebo acupressure and the no
treatment groups.

This study showed improved sleep

quality in renal dialysis patients
after receiving acupressure.
 Research Findings
Auth Year Partici Age Study Interve Detail Topic and Activity Major Finding
or pant Design ntion

Shari 2012 Interve 18-60 RCT Acupre The time of interventions was limited to This study showed there was a
ati, ntion: ssure 15 min; consisting of 9min of acupoints significant different in in global
Jahan 22 plus massage (3min per acupoint) and 6min of PSQI score (p<0.001) and all sleep
i, routine massage the areas near the acupoints to quality indices: subjective sleep
Hoos Control care vs. relax the person. quality, sleep latency, sleep
hman : 22 routine duration, sleep disturbances, and
d, & care One course of the intervention consisted daytime functional status (p<0.001);
Khalil of 3 days per 
week. These interventions sleep efficiency (p=0.006), and use
i. were carried out over four consecutive of sleeping medications (p=0.028).
weeks. 

The results of this study showed
The precision of acupressure was that acupressure can quickly and
confirmed if subjects felt sore, numb, effectively improve ESRD patients’
heavy, distended, and/or warm. quality of sleep.

Acupressure intervention was done by

harmonization method using fingertips
applying consistent pressure on the correct
acupoints with small rotational
movements. This action was done rapidly
at the rate of 2-rotations/s. 


The control group only received routine

care.
Result Conclusion
Although none of these studies can change the poor
sleepers to become good sleepers (PSQI <5), both
studies showed significantly different global PSQI score
from before and after the application of acupressure
(p<0.001).
Acupressure has been proven to increase the quality of
sleep in ESRD patients undergoing hemodialysis. Also
showed that those who did not get the intervention to
have the same score or even worsen sleep quality in the
4 weeks of the study.
Implementation in Clinical Settings
In Indonesia, new hemodialysis patients are increasing each
year, although there has not been any study conducting sleep
quality in hemodialysis patients in Indonesia, poor sleep
quality is most likely to be a problem as well as it is in any
other countries. So, the idea of implementing acupressure to
treat poor sleep quality in clinical setting is quite promising.
The nurses can assess patients sleep quality and apply the
acupressure to those who needs it. The use of this low-cost and
simple method may bring comfort to patients and enhance
their quality of life
References
• Indonesia Renal Registry. (2014). 7th Report Of Indonesian Renal Registry. Indonesia:
Perkumpulan Nefrologi Indonesia.
• KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. (2015).
American Journal Of Kidney Diseases, 66(5), 884-930.
http://dx.doi.org/10.1053/j.ajkd.2015.07.015
• Curtin, R. B., et al. (2002). Hemodialysis patients’ symptom experiences: Effects on physical
and mental functioning/Commentary and response. Nephrology Nursing Journal 29(6):
562.
• Weisbord, S., Fried, L., Arnold, R., Rotondi, A., Fine, M., Levenson, D., & Switzer, G. (2004).
Development of a symptom assessment instrument for chronic hemodialysis patients: the
dialysis symptom index. Journal Of Pain And Symptom Management, 27(3), 226-240. Pai,
M., Hsu, S., Yang, S., Ho, T., Lai, C., & Peng, Y. (2007). Sleep Disturbance in Chronic
Hemodialysis Patients: The Impact of Depression and Anemia. Renal Failure, 29(6), 673-
677. http://dx.doi.org/10.1080/08860220701459642
• Trbojevic-Stankovic, J., Stojimirovic, B., Bukumiric, Z., Hadzibulic, E., Andric, B., &
Djordjevic, V. et al. (2014). Depression and quality of sleep in maintenance hemodialysis
patients. Srp Arh Celok Lek, 142(7-8), 437-443. http://dx.doi.org/10.2298/sarh1408437t
References
• Sekercioglu, N., Curtis, B., Murphy, S., & Barrett, B. (2015). Sleep quality
and its correlates in patients with chronic kidney disease: a cross-sectional
design. Renal Failure, 37(5), 757-762.
• Gusbeth-Tatomir, P., Boisteanu, D., Seica, A., Buga, C., & Covic, A.
(2007). Sleep disorders: a systematic review of an emerging major clinical
issue in renal patients. Int Urol Nephrol, 39(4), 1217-1226.
• Masoumi, M. (2015). Sleep quality in patients on maintenance
hemodialysis and peritoneal dialysis. Sleep Medicine, 16, S72.
http://dx.doi.org/10.1016/j.sleep.2015.02.181
• Ezzat, H. & Mohab, A. (2015). Prevalence of sleep disorders among ESRD
patients. Renal Failure, 37(6), 1013-1019.
THANK YOU!