RESEARCH ARTICLE


The Effect of Virtual Reality and Hugo Point Massage on the Pain and Anxiety of School-aged Children with Cancer: Crossover Clinical Trial



Mohammad Saeidi1, Mohammad Arshadi Bostanabad2
iD
, Mahnaz Jabraeili2, *
iD

1 Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Pediatrics, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Article Information


Identifiers and Pagination:

Year: 2023
Volume: 17
E-location ID: e187443462309110
Publisher ID: e187443462309110
DOI: 10.2174/0118744346248844231003110642

Article History:

Received Date: 12/02/2023
Revision Received Date: 20/06/2023
Acceptance Date: 26/06/2023
Electronic publication date: 16/11/2023
Collection year: 2023

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Creative Commons License
© 2023 Saeidi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Pediatrics, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran; Tel: 041-34796770; E-mail: Jabraeilim@gmail.com


Abstract

Background:

Venipuncture and peripheral intravenous cannulation are two of the most common invasive procedures in children that generate pain and distress. Previous studies have confirmed the effect of distraction and acupressure on reducing pain and anxiety in children; however, the effectiveness of these two methods has not been compared.

Objective:

The aim of this study was to compare Virtual Reality and Hugo point massage on the pain and anxiety of children.

Methods:

This crossover study was conducted in the oncology unit of a children’s hospital. Participants included 30 children aged 6-12 with cancer who were randomly assigned to one of the three groups: (routine, Virtual Reality, and acupressure). All children experienced these three methods. The scores of children’s pain (VAS scale) and anxiety (FAS scale) were measured.

Finding:

The result showed that the Virtual Reality method significantly reduced pain and anxiety compared to Hugo’s point method (P <0.001).

Implications for Nursing:

According to the present study, non-pharmacological methods such as Hugo point massage and virtual reality were effective in reducing pain and anxiety in school-aged children. Therefore, nursing managers can encourage nurses to use these methods based on the child's preferences to relieve the pain by providing the necessary facilities and equipment. Furthermore, they can increase nurses' knowledge by introducing new pain management methods in children through workshops.

Conclusion:

The present study showed that VR and Hugo’s point massage were effective ways to reduce pain and anxiety resulting from intravenous cannulation in school-age children.

Clinical Trial Registration Number: IRCT20100823004617N14.

Keywords: Virtual reality, Hugo point, Pain, Anxiety, Children, Cancer.

1. INTRODUCTION

Cancer is the second leading cause of death in children and adolescents [1]. Cancer cause 20.1% of all deaths in children aged 5-9 years [2]. Cancer treatment is time-consuming and often requires the child to be hospitalized. During hospitalization, the child is exposed to invasive and repeated painful procedures [3, 4]. Children with cancer undergo several potentially painful procedures, such as accessing the peripheral or central venous or bone marrow aspiration [5]. These procedures can cause pain in the child [6]. Pain has numerous psychological effects, such as stress, fear, and anxiety [7]. Anxiety is a mental, emotional response to stressful factors [8].

Conducting painful medical procedures in these children is unavoidable [9, 10]. Venipuncture and peripheral intravenous cannulation are two of the most common invasive procedures in children [11-14] that generate pain and distress [15, 16]. Management of pain and anxiety during venipuncture is performed using pharmacological and non-pharmacological methods [17].

Non-pharmacological methods are recommended to relieve pain related to venipuncture /peripheral intravenous cannulation in children [15, 18]. These methods include Physical (sensory), Psychological, and Spirituality and religious interventions [19].

Among non-pharmacological methods, distraction is one of the most practical, straightforward, and cost-effective methods for relieving pain and anxiety [20-22]. Distraction is the shift of attention from painful stimuli to more attractive or pleasurable ones [23]. According to a study, distraction techniques can reduce pain and anxiety in children [24-26]. There are numerous types of distraction, including visual, auditory, tactile, and mental [22], and choosing a distraction type is directly related to the age of the child [21]. Virtual reality (VR) is one of the ways of distraction. In this method, computerized technology is used to immerse a person in a multi-sensory, three-dimensional environment [27]. A systematic review recommended further research on the effect of VR associated with medical procedures due to insufficient research in this field [28].

Another non-pharmacological method in the physical intervention group is acupressure [21, 24, 29]. This safe, straightforward and inexpensive method is recommended by the World Health Organization [30, 31]. The points used in acupuncture are massaged [30]. Hugo point (LIIV) is the most important analgesic point of the body, located between the first and second metacarpals bones [32, 33]. According to the gate control theory of pain, massage can effectively close the gate. In other words, by stimulating the large nerve fibers, the perception of pain changes, preventing the transmission of painful stimuli [34]. According to the American Academy of Pediatrics, pain is an intrinsic multifactorial experience and should be evaluated and treated [24]. Preventing pain in children is a moral commitment [18], and nurses have an influential role in pain management. Therefore, their pain management program might impact patients' pain experience [35].

Previous studies have confirmed the effect of distraction and acupressure on reducing pain and anxiety in children; however, the effectiveness of these two methods has been less compared. Thus, the aim of this study was to compare the effectiveness of the two non-pharmacological techniques, namely Virtual Reality and Hugo’s point massage, on the pain and anxiety of children undergoing intravenous cannulation.

2. MATERIALS AND METHODS

2.1. Trial Design

This crossover randomized clinical trial study was conducted from November 2019 to May 2020 in Iran.

2.2. Participants

Participants included 30 children aged 6-12 with cancer admitted to the oncology unit. The oncology unit is a referral center with approximately 40 beds, in which children with Anemia, leukemia (ALL, AML), Congenital coagulation diseases, Nephroblastoma, and Neuroblastoma are admitted. Participants were included in this study through a convenience sampling method.

2.2.1. Eligibility Criteria for Participants

Inclusion criteria included experience with peripheral intravenous cannulation, alertness, and the ability to communicate verbally. Children who had used pain relievers 8 hours before intravenous cannulation or had a previous injury at the site of Hugo’s point were excluded from the study.

2.3. Study Setting

This study was conducted in a children’s hospital, a referral center in East Azerbaijan, Iran.

2.4. Procedures

Peripheral intravenous cannulation was performed with peripheral IV catheter No.22-24 (Soha Company) for all children by a skilled and experienced nurse. In both groups, the mother was present at her child's bedside during the procedure.

2.4.1. Control Group

In the control group, the child was comforted only by the mother; consequently, before, during, and after the procedure, the mother performed multisensory interventions such as talking, touching, kissing, and eye-to-eye contact with the child.

2.4.2. Virtual Reality (VR)

In this method, in addition to maternal multisensory interventions, from five minutes before the intravenous cannulation, until the end of it, a “SpongeBob” cartoon was shown through a cyberspace camera placed over the patient's eyes and ears.

2.4.3. Hugo’s Point Massage

In addition to maternal multisensory interventions, five minutes before the intravenous cannulation, Hugo’s point in the opposite hand was massaged in a circular motion, in a clockwise direction, with moderate pressure by researcher who was previously trained in this field. The maximum pressure time was one minute at a time, and then the massage was interrupted for 10 seconds. This operation continued until the intravenous cannulation was completed.

2.5. Randomization and Allocation

Randomization was conducted using a randomized block design with blocks of 6 and 9. Allocation concealment was performed using sealed envelopes with consecutive numbers. The child was asked to choose one of the sealed envelopes. Each envelope contained a triple block (A=VR, B = Hugo’s point massage, C= routine) showing the order of the intervention on the child. For example, if the blocking arrangement assigned to the child was ABC, the child would experience VR, Hugo’s point massage, and routine interventions sequentially. The washout period was considered to be 24 to 72 hours. If a child needed peripheral intravenous cannulation less than this time, he/she would be excluded from the study.

2.6. Outcome Measure

In this study, Visual Analog (VAS) [37] and Faces Anxiety Scales (FAS) were used to measure child pain and anxiety, respectively [38].VAS scale is a 10-cm horizontal line that includes a range from painless to most painful, in which the child is asked to mark the area on the line that best describes the amount of pain experienced immediately after the intravenous cannulation. The FAS scale is made up of drawings of five faces. The left and right images of the scale indicate the absence and the highest level of anxiety, respectively. The scores on the instrument range between 0-10.

Children’s pain and anxiety were measured five minutes before and one minute after the procedure. To calculate the child's pain score, one minute after the procedure, the researcher’s assistant asked the child to show the amount of pain during the procedure on the scale. The distance between the point indicated by the child and the pain-free point was measured with a ruler and recorded as the child's pain or anxiety score.

Blinding the participants was unattainable; however, the co-researcher responsible for collecting the data and those who analyzed the data were blind to the study groups.

2.7. Sample Size

The sample size was determined based on Lestari et al.’s study, 2017. Considering the pain mean differences in the intervention group (4.11±1.79) and the control group 5.79±1.78), 95% confidence interval, a significance level of one-sided α = 0.05, 80% power, and 1: 1 allocation ratio, the sample size was obtained as 24 participants, which increased to 30 considering a 20% potential attrition rate [36].

2.8. Ethical Consideration

This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (registered in the international center for the registration of clinical trials in (IRCT20100823004617N14). Researchers explained the purpose of the study to the child and his/her parents before collecting the data and then obtained informed written consent from them. Participants had the right to withdraw from the study at any stage.

2.9. Data Analysis

Data were analyzed using SPSS software version 26. The normality of the data was assessed using the Kolmogorov-Smirnov test. Descriptive statistic tests such as Frequency (percentage) and mean ± standard deviation were used to describe qualitative and quantitative data. In addition, a paired sample t-test was used to compare intra-group pain and anxiety scores before and after the intervention. One-way ANOVA was applied to compare children’s pain and anxiety scores between the groups. The level of statistical significance was considered less than 0.05% (Fig. 1).

3. RESULT

In the present study, 115 children were selected: 32 children due to lack of inclusion criteria (17 children due to having a central vein, 5 vision problems, 10 the first experience of venipuncture) and 53 children for decline to participate (20 child's restlessness, 8 parents' refusal to take the child's vein, 25 parents' lack of belief in the effectiveness of interventions) were excluded from the study. Finally 30 children were studied. The mean age of the children was 9.1±1.82. Children’s most common type of cancer was acute lymphocytic leukemia (ALL), with 13 cases (43.3%). The children’s demographic characteristics are provided in Table 1.

Table 1. The demographic characteristics of the children with cancer.
Variable - N (%)
Gender Boy 16 (53.3)
Girl 14 (46.7)
Place of residence City 12(40)
Village 18(60)
Economic situation Poor 15(50)
Modrate 10(33.3)
Good 5(16.7)
Type of Cancer ALL 13 (43.3)
AML 5 (16.7)
Hodgkin's lymphoma 4 (13.3)
Sarcoma 2 (6.7)
Neuroblastoma 6 (2)
Mean ± Sd
Number of Hospitalizations 2.9 ± 1.06
Number of Times chemotherapy 3.23 ± 1.14
Fig. (1). Consort flowchart diagram.

Table 2. Comparison of pain and anxiety scores of children with cancer in three methods of distraction, acupressure and routine.
Variable Method Pre-test Post-test Intra-group Comparison
P-value
Mean± SD Mean± SD
Anxiety Virtual reality 6.27 ± 1.79 3.07 ± 1.26 P< 0.001*
Hugo 6.67 ± 1.42 5.00 ± 1.72 P< 0.001*
Routine 6.53 ± 1.73 6.13 ± 1.74 P= 0.23*
Inter-group comparison
P-value		 P>0.05** P<0.001**
Pain Virtual reality 1.43 ± 1.19 3.86 ± 1.11 P< 0.001*
Hugo 1.75 ± 0.91 5.31 ± 1.14 P< 0.001*
Routine 2.15 ± 0.99 7.16 ± 0.96 P= 0.888*
Inter-group comparison
P-value		 P>0.05 ** P<0.001** -
Note: *Paired sample t-test
** One-away ANOVA.
Table 3. Comparison of changes in pain and anxiety scores of children with cancer in three methods of distraction, acupressure and routine.
Variable Method Pre-test Mean Difference (confidence limits) P-value
Mean± SD
Anxiety Virtual reality Hugo 1.93 (-1.32 to -2.55) <0.001*
Routine -3.07 (-2.39 to -3.74) <0.001*
Hugo Virtual reality 1.93 (1.32 to 2.55) <0.001*
Routine -1.13 (-0.46 to -1.86) <0.001*
Routine Virtual reality 3.07 (2.39 to 3.74) <0.001*
Hugo 1.13 (0.46 to 1.81) <0.001*
Pain Virtual reality Hugo -1.52 (-1.01 to -2.04) <0.001*
Routine -3.31 (-2.75 to -3.86) <0.001*
Hugo Virtual reality 1.52 (1.01 to 2.04) <0.001*
Routine -1.78 (-2.15 to -1.42) <0.001*
Routine Virtual reality 3.31 (2.75 to 3.86) <0.001*
Hugo 1.78 (1.42 to 2.15) <0.001*
Note: *Tukey Post Hoc.

The intra-group comparison showed that the child's pain and anxiety scores decreased after intervention in VR and Hugo’s methods, which was statistically significant (P <0.001). Although the pain and anxiety scores decreased in the control group, it was not statistically significant (P <0.05). ANOVA test was used to compare the inter-group mean pain and anxiety scores. The results showed that children in Hugo’s and VR methods experienced less pain and anxiety than the control group, which was statistically significant (P <0.001) (Table 2).

The Post-Hoc Tukey test was used to determine the most effective method for relieving the child's pain and anxiety. The results showed that the lowest score of the child's pain and anxiety was related to VR, the pressure, and the control group, respectively (P <0.001) (Table 3).

4. DISCUSSION

The aim of this study was to investigate the effectiveness of two non-pharmacological methods, namely VR and Hugo’s point massage, on the pain and anxiety of children aged 6 to 12 years undergoing intravenous cannulation. The result showed that despite the effectiveness of both methods in relieving children's pain and anxiety, VR was more effective than Hugo’s point massage.

The effectiveness of acupressure on children's pain and anxiety resulting from venipuncture has been reported in previous studies [16, 41], in which the pain and anxiety scores in the acupressure group were lower than the control group.

In the present study, pain and anxiety scores in the VR group were lower than in the control group. These results are in line with previous studies. In this regard, studies showed that children in the VR group experienced less pain than the control group during painful procedures [7, 38-43]. Moreover, a study by Ryu, 2019 showed that VR was effective in reducing preoperative anxiety in children [44]. VR increases the pain threshold by diverting the child's attention [44-46].

In the study by Burns-Nader et al., using distraction was ineffective in reducing the pain and distress of children aged 4-11 years [47]. The probable reason for the difference between the findings of this study and the present study is the difference in the type of distraction. In this study, a tablet was used for child distraction.

In the present study, VR had a more significant effect in decreasing children's pain and anxiety than Hugo’s point massage. The researchers did not find a similar study in this regard.

VR offers an innovative method to manage pain through the integration of immersive visual and auditory techniques [48]. In fact, audiovisual distraction is a strong and effective intervention for pain relief in school-age children [25]. According to previous studies, distraction methods, such as three-dimensional VR glasses, are as effective in reducing pain, fear, and anxiety in children as medical techniques [49]. It seems that the VR method is a multi-sensory intervention and is, therefore, more effective than Hugo’s point massage, which is a mono-sensory intervention.

It is better to apply pain reduction techniques according to children’s age and mental and physical status. In school-age children vision development and coordination between the optic nerve and muscle have taken place, and the child is fascinated by exciting computer and electronic games [50]. A review study recommends the use of Hugo’s point massage at ages 6 to 12 and VR at ages 8 to 12 to reduce the pain of venipuncture in children [24].

To the best of the authors' knowledge, this was the first study to compare the effectiveness of Hugo’s point massage and VR. In this study, the crossover method was used, which is a powerful method for controlling confounders. One of the limitations of the present study was the participants’ limited age range. School-age children 6 - 12 years were studied, which resulted in a small sample size and a prolonged sampling period.

CONCLUSION

The present study showed that VR and Hugo’s point massage were effective ways to reduce pain and anxiety resulting from intravenous cannulation in school-age children. Therefore, nursing managers can encourage nurses/ occupational therapists to use these methods based on the child's preferences to relieve the pain by providing the necessary facilities and equipment. Furthermore, they can increase nurses' knowledge by introducing new pain management methods in children through workshops. In this study, the effect of VR and Hugo’s point pressure on children's pain and anxiety were compared due to the lack of studies in this field. It is suggested that more studies be conducted.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE

The research was initiated after confirmation by the Ethical Committee (IR.TBZMED.REC.1398.115), of Tabriz University of Medical Sciences and registries in Iran Clinical Trial Registration Center (IRCT20100823004617N14)9).

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from all participants

STANDARDS OF REPORTING

CONSORT guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS

The datasets generated and/or analyzed during the present study are in Persian and are not publicly available due to the confidentiality of the participants, yet they are available from the corresponding author at reasonable request [M.J].

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

The authors would like to thank the Research Deputy of Tabriz University of Medical Sciences (Iran) for approving the research, as well as the mothers and children who participated in this study.

REFERENCES

[1] Cunningham RM, Walton MA, Carter PM. The major causes of death in children and adolescents in the United States. N Engl J Med 2018; 379(25): 2468-75.
[2] Kyu HH, Stein CE, Boschi Pinto C, et al. Causes of death among children aged 5–14 years in the WHO European Region: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Child Adolesc Health 2018; 2(5): 321-37.
[3] Yan C, Cheung RS-y, Wong CL. Stress and perception of procedural pain management in Chinese Parents of Children with cancer. J Pain Symptom Manage 2021; 61(1): 90-102.e5..
[4] Sposito AMP, Silva-Rodrigues FM, Sparapani VC, Pfeifer LI, de Lima RAG, Nascimento LC. Coping strategies used by hospitalized children with cancer undergoing chemotherapy. J Nurs Scholarsh 2015; 47(2): 143-51.
[5] Loeffen EAH, Mulder RL, Font-Gonzalez A, et al. Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline. Eur J Cancer 2020; 131: 53-67.
[6] Robb SL, Hanson-Abromeit D. A review of supportive care interventions to manage distress in young children with cancer and parents. Cancer Nurs 2014; 37(4): E1-E26.
[7] Ballard A, Khadra C, Adler S, Doyon-Trottier E, Le May S. Efficacy of the Buzzy® device for pain management of children during needle-related procedures: a systematic review protocol. Syst Rev 2018; 7(1): 78.
[8] Videbeck S. Psychiatric-mental health nursing. 9th ed.. Lippincott Williams & Wilkins 2022.
[9] Maclaren JE, Cohen LL. Interventions for paediatric procedure-related pain in primary care. Paediatr Child Health 2007; 12(2): 111-6.
[10] Hamedi V, Hamid N, Beshlideh K, Marashi SA, Hashemi Sheikh Shabani SE. Effectiveness of conventional cognitive-behavioral therapy and its computerized version on reduction in pain intensity, depression, anger, and anxiety in children with cancer: A randomized, controlled trial. Iran J Psychiatry Behav Sci 2020; 14(4)
[11] Hashad RE-S, Ahmed GEN, Hashem SF, et al. Effect of nursing management protocol for pain and anxiety associated with intravenous cannulation on nurses and pediatric patient’s outcomes. Int J Novel Res Healthc Nurs 2020; 7(3): 423-243.
[12] Düzkaya DS, Bozkurt G, Ulupınar S, Uysal G, Uçar S, Uysalol M. The effect of a cartoon and an information video about intravenous insertion on pain and fear in children aged 6 to 12 years in the pediatric emergency unit: A randomized controlled trial. J Emerg Nurs 2021; 47(1): 76-87.
[13] Zempsky WT. Optimizing the management of peripheral venous access pain in children: Evidence, impact, and implementation. Pediatrics 2008; 122(S3): S121-4.
[14] Ben Abdelaziz R, Hafsi H, Hajji H, et al. Full title: Peripheral venous catheter complications in children: predisposing factors in a multicenter prospective cohort study. BMC Pediatr 2017; 17(1): 208.
[15] Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: A randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs 2018; 42: e66-72.
[16] Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in hugo point and music on severity of pain during iv insertion in children. Pak J Med Health Sci 2020; 14(2): 697-700.
[17] Dezfouli SMM, Khosravi S. Systematic review of the effective factors in pain management in children. Pak J Med Health Sci 2020; 14(2): 1236-43.
[18] Katende G, Mugabi B. Comforting strategies and perceived barriers to pediatric pain management during IV line insertion procedure in Uganda’s national referral hospital: A descriptive study. BMC Pediatr 2015; 15(1): 122.
[19] Plante‐Lepage R, Voyer P, Carmichael PH, et al. A nursing mentoring programme on non‐pharmacological interventions against BPSD: Effectiveness and use of antipsychotics—A retrospective, before–after study. Nurs Open 2021; 9(1): 181-8.
[20] Balanyuk I, Ledonne G, Provenzano M, et al. Distraction technique for pain reduction in peripheral venous catheterization: Randomized, controlled trial. Acta Biomed 2018; 89(4-S): 55-63.
[21] Makvandi S, Karimi L, Mahdavian M. A systematic review and meta-analysis of the effect of acupressure on relieving the labor pain. Iran J Nurs Midwifery Res 2020; 25(6): 455-62.
[22] Jacobson AF. Cognitive-behavioral interventions for IV insertion pain. AORN J 2006; 84(6): 1031-48.
[23] Akgül EA, Karahan Y, Başoğlu F, et al. Effects of watching cartoons on pain scores in children undergoing venepuncture. Nurs Child Young People 2018; 33(3)
[24] Rezai MS, Goudarzian AH, Jafari-Koulaee A. The effect of distraction techniques on the pain of venipuncture in children: A systematic review. J Pediatr Rev 2017; 5(1): 26-37.
[25] Oliveira NCAC, Santos JLF, Linhares MBM. Audiovisual distraction for pain relief in paediatric inpatients: A crossover study. Eur J Pain 2017; 21(1): 178-87.
[26] Kaheni S, Sadegh Rezai M, Bagheri-Nesami M, et al. The effect of distraction technique on the pain of dressing change among 3-6 year-old children. Int J Pediatr 2016; 4(4): 1603-10.
[27] Kenney MP, Milling LS. The effectiveness of virtual reality distraction for reducing pain: A meta-analysis. Psychol Conscious 2016; 3(3): 199-210.
[28] Eijlers R, Utens EMWJ, Staals LM, et al. Meta-analysis: Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesth Analg 2019; 129(5): 1344-53.
[29] Pak SC, Micalos PS, Maria SJ, et al. Nonpharmacological interventions for pain management in paramedicine and the emergency setting: A review of the literature. Evid Based Complement Alternat Med 2015; 2015: 873039.
[30] Micozzi MS. Fundamentals of complementary and alternative medicine-E-book. Elsevier Health Sciences 2014.
[31] Seyfari B, Mohsenpour Z, Moeindarbary S, et al. The effect of LI14 acupressure on children undergoing painful procedures and infants’ apgar score: An overview. Int J Pediatr 2020; 8(10): 12151-6.
[32] Arab V, Bagheri-Nesami M, Mousavinasab SN, Espahbodi F, Pouresmail Z. Comparison of the effects of hegu point ice massage and 2% lidocaine gel on arteriovenous fistula puncture-related pain in hemodialysis patients: A randomized controlled trial. J Caring Sci 2017; 6(2): 141-51.
[33] Jafari H, Shorofi S, Taherian T, et al. The effect of Hegu point ice massage on pain relief: A review article. Int J Pharm Technol 2016; 8(3): 4821-43.
[34] Adams R, White B, Beckett C. The effects of massage therapy on pain management in the acute care setting. Int J Ther Massage Bodywork 2010; 3(1): 4-11.
[35] Germossa GN, Hellesø R, Sjetne IS. Hospitalized patients’ pain experience before and after the introduction of a nurse-based pain management programme: A separate sample pre and post study. BMC Nurs 2019; 18(1): 40.
[36] Lilik Lestari MP, Wanda D, Hayati H. The effectiveness of distraction (Cartoon-Patterned Clothes and Bubble-Blowing) on pain and anxiety in preschool children during venipuncture in the emergency department. Compr Child Adolesc Nurs 2017; 40(sup1): 22-8.
[37] Cline M, Herman J, Shaw ER, Morton RD. Standardization of the visual analogue scale. Nurs Res 1992; 41(6): 378-9.
[38] McKinley S, Coote K, Stein-Parbury J. Development and testing of a Faces Scale for the assessment of anxiety in critically ill patients. J Adv Nurs 2003; 41(1): 73-9.
[39] Khalf-Allah SH, Ghazaly MH, Mohammed FZ, et al. Efficacy of acupressure and massage with ice for huko point on pain intensity during venipuncture in children with Thalassemia. Assiut Sci Nurs J 2018; 6(14): 22-31.
[40] Pouraboli B, Abazari F, Rostami M, et al. Comparison the effect of two methods of acupressure and massage with ice on Huko point on pain intensity during IV insertion in pediatrics with thalassemia. J Pediatr Nurs 2015; 2(2): 20-7.
[41] Foroogh Ameri G, Shah Mohammadi Pour P, Kazemi M, et al. Comparison of the effect of EMLA cream and acupressure on pain Reduction of venipuncture in 6-12 years old children. J Pediatr Nurs 2016; 2(4): 16-22.
[42] Semerci R, Akgün Kostak M, Eren T, Avci G. Effects of virtual reality on pain during venous port access in pediatric oncology patients: A randomized controlled study. J Pediatr Oncol Nurs 2021; 38(2): 142-51.
[43] Chen YJ, Cheng SF, Lee PC, Lai CH, Hou IC, Chen CW. Distraction using virtual reality for children during intravenous injections in an emergency department: A randomised trial. J Clin Nurs 2020; 29(3-4): 503-10.
[44] Ryu JH, Oh AY, Yoo HJ, Kim JH, Park JW, Han SH. The effect of an immersive virtual reality tour of the operating theater on emergence delirium in children undergoing general anesthesia: A randomized controlled trial. Paediatr Anaesth 2019; 29(1): 98-105.
[45] Asl Aminabadi N, Erfanparast L, Sohrabi A, Ghertasi OS, Naghili A. The impact of virtual reality distraction on pain and anxiety during dental treatment in 4-6 year-old children: A randomized controlled clinical trial. J Dent Res Dent Clin Dent Prospect 2012; 6(4): 117-24.
[46] Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: Current trends and future directions. Pain Manag 2011; 1(2): 147-57.
[47] Burns-Nader S, Atencio S, Chavez M. Computer tablet distraction in children receiving an injection. Pain Med 2016; 17(3): pme12877.
[48] Ang SP, Montuori M, Trimba Y, Maldari N, Patel D, Chen QC. Recent applications of virtual reality for the management of pain in burn and pediatric patients. Curr Pain Headache Rep 2021; 25(1): 4.
[49] Babaie M, Shirinabadi FA, Nourian M, et al. Pain management using distraction in school-age children. Iran J Nurs Res 2015; 10(3): 71-80.
[50] Hockenberry MJ, Wilson D. Wong’s nursing care of infants and children-E-book. Elsevier Health Sciences 2018.