Subjects' Selection:~The patients will be randomly assigned to 3 groups;~Group (1) will receive (TENS , cryotherapy and conventional physical therapy program).~Group (2) will receive (distractive techniques , cryotherapy and conventional physical therapy program).~Group (3) will receive (cryotherapy and conventional physical therapy program). Patients will be assessed for quality of life before and after treatment and will receive 3 sessions per week consisted of TENS, distractive techniques , Cryotherapy and conventional physical therapy program during AVF Puncture during dialysis for 4 weeks.~1-Inclusion criteria:~Patient age will range from 20 - 60 years who have chronic renal failure from males and females.~At least one year passed from the installation of AVF and hemodialysis.~Patients are undergoing hemodialysis three sessions per week and each session lasting for 4 hours.~Having no traces of skin abnormalities or analgesia in vessels access point.~2-Exclusion Criteria:~The following were considered exclusion criteria:~Unwillingness to continue with the study.~Unsuccessful AVF cannulation at the first try.~Patients having radiation injuries, peripheral vascular diseases, Raynauld's disease, connective tissue disorders, diabetic neuropathy, unconsciousness or disorientation.~Presence of infection and obstruction of fistula based on the nurse's inspection.~The presence of auditory and visual disturbances.~history of verbal disturbances; no addiction or drug dependence to pain medications; no history of mental health diseases; being conscious, having not taken painkillers, narcotics or sedatives at least six hours before hemodialysis.~Having traces of severe pain in other parts.~Having pacemakers. The patients will be randomly assigned to 3 groups; Group(1) will receive TENS , cryotherapy and conventional physical therapy program, Group(2) will receive distractive techniques , cryotherapy and conventional physical therapy program and Group(3) will receive cryotherapy and conventional physical therapy program.~All groups will be assessed for quality of life using Kidney Disease Quality of Life Short Form Scale (KDQOL-SF) before and after treatment.
Statement of the problem:~This study will be conducted to answer the following question:~Is there a difference in the efficacy of TENS and distractive techniques when combined with cryotherapy in managing pain due to arteriovenous fistula puncture and improving quality of life in hemodialysis patients ?~Null Hypotheses:~TENS has no statistically significant effect on pain management and quality of life in hemodialysis patients undergoing arteriovenous fistula puncture.~Distractive techniques have no statistically significant effect on pain management and quality of life in hemodialysis patients undergoing arteriovenous fistula puncture.~There is no statistically significant difference between TENS and distractive techniques in managing pain and improving quality of life in hemodialysis patients undergoing arteriovenous fistula puncture.