Society for Pediatric Pain Medicine
Better Care for Children in Pain

Picture from A Manual of ACUPUNCTURE by Peter Deadman and Mazin Al-Khafaji, with Kevin Baker. The Journal of Chinese Medicine, 2nd edition, 2007. Digital format


Correct Answer: E. All of the above statements are true.


LI-4 is a very commonly used acupuncture point used in the treatment of pain and anxiety. It is located on the dorsum of the hand, at the most prominent point of the thenar muscle, on the radial side of the midpoint of the second metacarpal. Because it is an easy point to locate, acupressure at this point can be easily performed and taught to patients, parents, or other medical providers. There are many studies demonstrating its effectiveness in the treatment of anxiety and headache when used in combination with other points^2,3,4,5. In medical acupuncture, it is known to be particularly useful in the treatment of a variety of head and face disorders¹ including toothache^6,7, jaw pain/spasms^8,9, rhinitis, nasal congestion, changes in taste10, and ear pain/tinnitus. It can also be used to relieve dysmenorrhea ^1,11,12. ---------------------------------------------------------------------------------------------- References:


1 A Manual of ACUPUNCTURE by Peter Deadman and Mazin Al-Khafaji, with Kevin Baker. The Journal of Chinese Medicine, 2nd edition, 2007. Digital format


2 Amini Rarani S, Rajai N, Sharififar S. Effects of acupressure at the P6 and LI4 points on the anxiety level of soldiers in the Iranian military. BMJ Mil Health. 2021 Jun;167(3):177-181. doi: 10.1136/jramc-2019-001332. Epub 2020 Feb 2. PMID: 32015185.


3 Coeytaux RR, Befus D. Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache. 2016 Jul;56(7):1238-40. doi: 10.1111/head.12857. Epub 2016 Jul 13. PMID: 27411557.


4 Doll E, Threlkeld B, Graff D, Clemons R, Mittel O, Sowell MK, McDonald M. Acupuncture in Adult and Pediatric Headache: A Narrative Review. Neuropediatrics. 2019 Dec;50(6):346-352. doi: 10.1055/s-0039-1695785. Epub 2019 Aug 29. PMID: 31466110.


5 Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016 Apr 19;4:CD007587. doi: 10.1002/14651858.CD007587.pub2. PMID: 27092807; PMCID: PMC4955729.


6 Grillo CM, Wada RS, da Luz Rosário de Sousa M. Acupuncture in the management of acute dental pain. J Acupunct Meridian Stud. 2014 Apr;7(2):65-70. doi: 10.1016/j.jams.2013.03.005. Epub 2013 Apr 11. PMID: 24745864.


7 Devanand Gupta, Deepak Ranjan Dalai, Swapnadeep, Parul Mehta, B Niranjanaprasad Indra, Saurabh Rastogi, Ankita Jain, Mudita Chaturvedi, Saumya Sharma, Sanjeev Singh, Shruti Gill, Nisha Singh, Rajendra Kumar Gupta. Acupuncture (針灸 Zhēn Jiǔ) – An Emerging Adjunct in Routine Oral Care. Journal of Traditional and Complementary Medicine. 2014;4(4). 218-223. ISSN 2225-4110. doi.org/10.4103/2225-4110.139113.


8 Shen YF, Younger J, Goddard G, Mackey S. Randomized clinical trial of acupuncture for myofascial pain of the jaw muscles. J Orofac Pain. 2009 Fall;23(4):353-9. PMID: 19888488; PMCID: PMC2894813.


9 Lu DP, Lu GP, Lu PM. Clinical effectiveness of acupuncture for mandibular subluxation and dislocation. Acupunct Electrother Res. 2010;35(3-4):187-92. doi: 10.3727/036012910803860896. PMID: 21319604.


10 Djaali W, Simadibrata CL, Nareswari I. Acupuncture Therapy in Post-Radiation Head-and-Neck Cancer with Dysgeusia. Med Acupunct. 2020 Jun 1;32(3):157-162. doi: 10.1089/acu.2020.1410. Epub 2020 Jun 16. PMID: 32595823; PMCID: PMC7310235


11 Huang T, Yang L, Jia S, Mu X, Wu M, Ye H, Liu W, Cheng X. Capillary blood flow in patients with dysmenorrhea treated with acupuncture. J Tradit Chin Med. 2013 Dec;33(6):757-60. doi: 10.1016/s0254-6272(14)60008-x. PMID: 24660607.


12 Bazarganipour F, Taghavi SA, Allan H, Beheshti F, Khalili A, Miri F, Rezaei M, Mojgori M, Imaninasab F, Irani F, Salari S. The effect of applying pressure to the LIV3 and LI4 on the symptoms of premenstrual syndrome: A randomized clinical trial. Complement Ther Med. 2017 Apr;31:65-70. doi: 10.1016/j.ctim.2017.02.003. Epub 2017 Feb 21. PMID: 28434473.

Correct Answer: B. Pain unpleasantness


Virtual reality (VR), a multimodal system that transports users into a fully immersive virtual world, has been explored as a complementary pain management strategy for many years. Until now, the primary use of VR in both pediatric and adult care has been distraction-based therapy during acutely painful procedures.^1–5 However, given the risks associated with opioid exposure in children, including after surgery,⁶ VR is now being explored as a method of helping to decrease postoperative pain and anxiety after surgery.^7–9


A pilot study done at Cincinnati Children’s Hospital Medical Center explored the use of a single, guided relaxation-based VR session (VR-GR) in children and adolescents following surgery.^8,10 Over a 9-month period, a total of 51 children and adolescents followed by the Acute Pain Service participated in a single, 10-minute session using the “Mindful Aurora” application (Invincikids, Palo Alto, CA). Baseline measurements of pain intensity, pain unpleasantness, and anxiety were taken for each patient and compared to these same values immediately following the experience as well as 15 and 30 minutes following session completion. The VR-GR session was associated with transient reductions in pain intensity, pain unpleasantness, and anxiety. Patient and family satisfaction with the experience was high. Future study is being done to assess the efficacy of VR in decreasing pain, anxiety, opioid, and benzodiazepine consumption via a randomized controlled trial allowing for further exploration of this alternative, non-pharmacological intervention.


References:


1. Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clin Psychol Rev. 2010;30(8):1011-1018. doi:10.1016/j.cpr.2010.07.001


2. Indovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual Reality as a Distraction Intervention to Relieve Pain and Distress During Medical Procedures: A Comprehensive Literature Review. Clin J Pain. 2018;34(9):858-877. doi:10.1097/AJP.0000000000000599


3. Mallari B, Spaeth EK, Goh H, Boyd BS. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis. J Pain Res. 2019;Volume 12:2053-2085. doi:10.2147/JPR.S200498


4. Garrett B, Taverner T, Masinde W, Gromala D, Shaw C, Negraeff M. A Rapid Evidence Assessment of Immersive Virtual Reality as an Adjunct Therapy in Acute Pain Management in Clinical Practice. Clin J Pain. 2014;30(12):1089-1098. doi:10.1097/AJP.0000000000000064


5. Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag. 2011;1(2):147-157. doi:10.2217/pmt.10.15


6. Harbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics. 2018;141(1):e20172439. doi:10.1542/peds.2017-2439


7. Olbrecht VA, Williams SE, O’Conor KT, et al. Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomised, controlled trial (FOREVR Peds trial). BMJ Open. 2020;10(12):e040295. doi:10.1136/bmjopen-2020-040295


8. Olbrecht VA, O’Conor KT, Williams SE, et al. Guided Relaxation-Based Virtual Reality for Acute Postoperative Pain and Anxiety: A Pilot Study in a Pediatric Population. J Med Internet Res. Published online May 4, 2021. doi:10.2196/26328


9. Olbrecht VA, O’Conor KT, Williams SE, et al. Transient Reductions in Postoperative Pain and Anxiety using Virtual Reality in Children. Pain Med Malden Mass. Published online June 27, 2021:pnab209. doi:10.1093/pm/pnab209


10. O’Conor KT, Olbrecht VA. Using Guided-Relaxation Based Virtual Reality to Manage Post-Surgical Pain and Anxiety in Children. Society for Pediatric Pain Medicine Newsletter. https://pedspainmedicine.org/wp-content/uploads/newsletters/2021/summer/VR/guided%20relax.html. Published Summer 2021. Accessed September 20, 2021.