{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T03:45:33Z","timestamp":1792035933081,"version":"4.4.0"},"reference-count":35,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T00:00:00Z","timestamp":1776729600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T00:00:00Z","timestamp":1776729600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Hemodialysis International"],"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Over 20% of patients undergoing hemodialysis are unable to tolerate the discomfort associated with vascular needle insertion, and nearly half (47%) report a fear of these needles, often identifying this step as the most distressing aspect of their treatment. Currently, no universally accepted method exists to alleviate this pain effectively. The objective of the present investigation was to assess and contrast the analgesic efficacy of the Valsalva maneuver and rhythmic breathing techniques in hemodialysis patients undergoing vascular access cannulation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Ninety participants undergoing hemodialysis at Semnan University's Kosar Hospital were randomly divided into three study arms (rhythmic breathing, Valsalva maneuver, control) in this clinical trial, using convenience sampling for enrollment. The rhythmic breathing intervention group performed controlled, rhythmic respiration cycles (lasting 1\u2009min every 5\u2009min) during the 20\u2009min preceding vascular access needle insertion. Patients assigned to the Valsalva group executed the technique for 16\u201320\u2009s just prior to vascular access needle placement. Participants in the control arm received routine clinical care and no supplementary interventions. Numerical pain rating scale measurements were obtained two minutes following needle insertion to quantify pain levels.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>\n                      Significantly lower pain scores were observed in both Valsalva maneuver (3.06\u2009\u00b1\u20092.39) and rhythmic breathing (3.03\u2009\u00b1\u20092.48) groups relative to controls (6.20\u2009\u00b1\u20091.49;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Subsequent analysis showed that both the Valsalva maneuver and rhythmic breathing groups experienced a markedly higher reduction in pain levels compared to the control group (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). However, the two interventions demonstrated comparable effectiveness, with no observable statistical difference between them (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.99).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The findings suggest that the Valsalva maneuver is equally effective as rhythmic breathing in minimizing pain during arteriovenous fistula (AV fistula) cannulation, and both methods can be recommended as non\u2010pharmacological pain relief strategies in hemodialysis patients.<\/jats:p>\n                    <jats:p>\n                      <jats:bold>Trial Registration:<\/jats:bold>\n                      Iranian Registry of Clinical Trials, Trial No: IRCT20120109008665N16. Registered 14 March 2024\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/hdi.70066","type":"journal-article","created":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T01:40:33Z","timestamp":1776822033000},"page":"549-556","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Comparison of the Effect of Valsalva Maneuver and Rhythmic Breathing on Pain Intensity During Vascular Needle Insertion in Hemodialysis Patients: A Randomized Controlled Clinical Trial"],"prefix":"10.1111","volume":"30","author":[{"given":"Sajad","family":"Salehipour","sequence":"first","affiliation":[{"name":"Nursing Care Research Center, Semnan University of Medical Sciences  Semnan Iran"},{"name":"Department of Nursing School of Nursing and Midwifery, Semnan University of Medical Sciences  Semnan Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zeynab","family":"Voloei","sequence":"additional","affiliation":[{"name":"Student Research Committee, Semnan University of Medical Sciences  Semnan Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Setayesh","family":"Hasanabadi","sequence":"additional","affiliation":[{"name":"Student Research Committee, Semnan University of Medical Sciences  Semnan Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatemeh","family":"Mohseni","sequence":"additional","affiliation":[{"name":"Student Research Committee, Semnan University of Medical Sciences  Semnan Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3786-7348","authenticated-orcid":false,"given":"Hassan","family":"Babamohamadi","sequence":"additional","affiliation":[{"name":"Nursing Care Research Center, Semnan University of Medical Sciences  Semnan Iran"},{"name":"Department of Nursing School of Nursing and Midwifery, Semnan University of Medical Sciences  Semnan Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,4,21]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.7475\/kjan.2022.34.2.205"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.4236\/ojn.2016.612098"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.2147\/JMDH.S344256"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.5812\/MSNJ.113511"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1155\/2022\/8383021"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfr355"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/hdi.12803"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.4103\/1319\u20102442.289446"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.11648\/j.ajim.20140205.12"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1755\u20106686.2004.tb00369.x"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.7150\/ijms.8.623"},{"key":"e_1_2_10_13_1","volume-title":"Fundamental of Nursing","author":"Potter P. 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