International Journal of Pediatric Otorhinolaryngology 79 (2015) 1263–1267

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Korean hand therapy for tonsillectomy pain in children

James W Ochi 1,2,*
The Northern Navajo Medical Center, PO Box 160, Hwy 491 North, Shiprock, NM 87420, USA

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Severe throat pain can result from tonsillectomy and last up to 10 days in children. Codeine
Received 10 March 2015 has recently been banned by the FDA in light of a recently recognized risk of death in these patients.
Received in revised form 6 May 2015 Acupuncture has previously been associated with decreased pain in children after tonsillectomy.
Accepted 20 May 2015
However, about 1 in 5 patients will refuse traditional acupuncture because of fear of needles. We
Available online 28 May 2015
explored Korean Hand Therapy (KHT), an acupuncture technique which does not involve needles, to see
if this would also be associated with pain relief and be more widely accepted by children.
Keywords:
Methods: This was a retrospective review of children who underwent tonsillectomy over a 4-month
Tonsillectomy
Pain
window. No narcotics were prescribed after surgery. Patients who wanted help with pain relief were
Children offered KHT. Perceived pain level was assessed before and after the KHT treatment. Following the 10-day
Korean hand therapy recovery for tonsillectomy, patients or their parents were queried as to how long the pain relief from the
Acupuncture KHT intervention was perceived to last.
Codeine Results: Fifty-six children underwent tonsillectomy; 29 of these patients (1–14 years) presented for pain
relief after tonsillectomy and received KHT. 100% of patients (29 of 29) who were offered KHT accepted
the intervention. The mean reported pain level before KHT was 5.03 (SD = 2.69) out of 10. This fell to 3.06
(SD = 3.15) after KHT. Statistical analyses supported the general conclusion that pain reports decline
after KHT in the sampled population. 15 patients who received KHT – or their parents – provided a post-
recovery report for how long they believed the KHT intervention lasted. The mean duration of perceived
KHT benefit was 78.20 h, though the standard deviation was large (64.38 h). With the exception of one
child reporting a slight increase in pain, no adverse effects were associated with KHT.
Conclusions: The data tentatively suggest KHT is associated with decreases in perceived pain after
tonsillectomy and is widely accepted by children. These data – combined with the cost effectiveness,
safety and ease of administering KHT – suggest that further studies exploring the effectiveness of KHT for
pain relief after tonsillectomy are merited.
ß 2015 Elsevier Ireland Ltd. All rights reserved.

1. Background Acupuncture in general has been shown to reduce pain [5], has
a low risk of complications [6], can be done quickly, and has
Tonsillectomy is one of the most frequently performed minimal cost (about 11 cents per needle, with many treatments
surgeries done worldwide; at least half a million tonsillectomies requiring five or less needles). In our previous study, acupuncture
are done every year in the United States alone [2]. This surgery was associated with decreased perceived pain in children after
often results in severe throat pain, which can last up to 10 days [3]. tonsillectomy [1]. However, a significant portion of these patients
Codeine elixir has long been prescribed for pain relief. However, (9 of 42 or about 21%) who presented for pain relief after
the Food and Drug Administration recently banned this because of tonsillectomy refused acupuncture because of their fear of
a recently recognized risk of death [4]. Young children may become needles.
dehydrated if they suffer significant throat pain and require Acupuncture is thousands of years old, but Korean Hand Therapy
intravenous fluids in an emergency department. (KHT) was developed in the 1970s [7]. KHT is an acupuncture
technique based upon the principles of traditional Chinese
acupuncture and can be performed without needles using small
* Tel.: +1 858 204 8502; fax: +1 858-259-6286. aluminum discs applied with tape on the hands (Fig. 1). KHT is also
E-mail address: jochi@integrativeENT.com
1 inexpensive (about 10 cents per disc, with the current treatment
Rady Children’s Hospital San Diego
2
Voluntary Assistant Clinical Professor of Surgery, UC San Diego School of using six stickers per patient) and comes with the added benefit that
Medicine, San Diego, CA patients do not need to disrobe—a possible requirement of

http://dx.doi.org/10.1016/j.ijporl.2015.05.027
0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
1264 J.W. Ochi / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1263–1267

Of the 56 patients who received surgery, 35 presented for pain

relief during the first 10 days after surgery. Five rated their pain
score as 0 and were not offered KHT. The rest, 30 patients, were all
offered KHT. One of these patients turned 18 during the study and
so exceeded the study age limit.
The final study sample consisted of 29 patients (12 females, 17
males) who agreed to have KHT. The mean age of this sample was
6.07 years (SD = 2.88 years, range = 1–14 years). Pain reports were
collected from these patients or their parents immediately before
and after the intervention.
Nineteen of these patients or their parents provided an
additional report after the 10-day recovery window, estimating
how long the benefits of the acupuncture intervention lasted.
Interestingly, four of these patients reported no change in pain
score at the time of the intervention but still provided the author
with an estimate of benefit duration. When the author inquired
Fig. 1. Korean Hand Therapy can be done with small (4 mm diameter) aluminum further with these four patients, they stated that they experienced
discs on an adhesive backing.
pain relief after returning home and believed it was due to the
intervention. Although the possibility of delayed benefit is
interesting, the reports of these patients were excluded on the
traditional acupuncture and a distinct source of discomfort for most chance that other interventions (e.g., parent administration of
children in a medical setting. alternative pain relief) influenced the reports. The final subsample
There is already some preliminary evidence that KHT is estimating benefit duration was 15 patients (6 females, 9 males)
effective at treating common sources of post-operative discomfort. who reported a change in pain score at the time of the KHT
For instance, KHT compared favorably with traditional acupunc- intervention. The mean age of this subsample was 5.87 years
ture at reducing post-operative nausea and vomiting in a (SD = 2.95 years, range = 1 to 11 years).
randomized, controlled trial of patients undergoing abdominal
hysterectomy [8]. This is especially striking given that the most 2.2. Tonsillectomy
recent Cochrane review on traditional acupuncture suggested that
it could be as effective as medication in preventing postoperative Patients received a total of 2–3 cc of 1% lidocaine with
nausea and vomiting in similar circumstances [9]. 1:100,000 epinephrine injected into both tonsil beds before the
We wanted to see if KHT could be applied in a novel post- start of surgery. An anesthetic technique using nitrous oxide and
operative context – following tonsillectomy – to give young sevoflurane was used for all patients. Tonsillectomy was done
patients meaningful relief from another common source of post- using monopolar electrocautery set at 24 W and all patients were
operative discomfort: pain. At the same time, we wanted to see if given intravenous dexamethasone 0.5 mg/kg up to a maximum of
KHT would be more widely accepted by young patients than 12 mg. A monopolar suction cautery hand piece set at the same
traditional acupuncture was in our previous study [1]. wattage was used for adenoid removals.
After the surgery, parents were advised that their children could
2. Methods eat or drink whatever they wanted, noting that fluid take should be
encouraged to reduce the risk of dehydration. Additionally,
2.1. Participants children could be as active as they wished (e.g., bike rides,
running, playing sports) and could swim, shower, or bathe
The author performed all surgeries and KHT techniques. All immediately on going home.
surgeries were performed at Rady Children’s Hospital San Diego. None of the patients were prescribed narcotics for use at home.
KHT was offered and performed – free of charge – at outpatient Parents were advised to respond to child requests for pain relief by
facilities in El Centro or Encinitas, CA during a standard post- administering the appropriate dose of acetaminophen or ibuprofen
operative visit. elixir, respecting child body weight and the time intervals given by
The study is a retrospective review of pediatric tonsillectomy the manufacturer.
patients. The patient pool was drawn from the author’s practice
and included all patients less than 18 years of age who underwent 2.3. Korean hand therapy intervention and pain reports
tonsillectomy during a 4-month period beginning June 10, 2014
and ending September 30, 2014. The Institutional Review Boards Patients were invited to return during the 10-day recovery if the
of UC San Diego granted approval for this retrospective chart family wanted help with pain relief. Upon arrival, the patient or
review. parent (pending patient age and apparent maturity) was asked to
Fifty-six children underwent tonsillectomy during the study use the Faces Pain Score – Revised Scale (Fig. 2) to assess current
period. In addition, all 56 patients also had adenoidectomy and 7 level of discomfort.
also had bilateral myringotomy and tube insertion. If the pain score was greater than zero, Korean Hand Therapy
There were no intra-operative complications and no patient had was offered free of charge for the patient. All patients had KHT
postoperative oropharyngeal bleeding. done on the right middle finger. This measurement was repeated
Not all 56 patients were considered in the current review. Only again after the treatment resulting in a ‘‘before’’ pain report and an
patients who presented for pain relief within the traditional 10- ‘‘after’’ pain report.
day tonsillectomy recovery window are included in the final data The hand points for KHT can be identified using a hand-held
analysis. It was not possible to collect pain data for patients who battery-operated point location device (Pointer Plus, Lhasa OMS,
did not participate in the follow-up visit at all and ‘‘after’’ reports Inc., Weymouth, MA). This instrument measures electrical
could not be collected for patients who participated in the visit but conductivity along the skin surface. The point finder helps the
did not receive KHT. practitioner identify active KHT points on the hands. The KHT
 J.W. Ochi / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1263–1267 1265

Fig. 2. FACES pain score – revised scale.

treatment used 6 sterile, single-use circular aluminum discs (Qi 3.1. Preliminary analyses
Mark Press Pellet, A Type, silver, small, Seoul, Korea) with a
diameter of 4 mm on an adhesive backing placed on the right Prior to conducting the primary statistical analysis, participant
middle finger at points designated as M5, E4 and E8 (Fig. 3). age, KHT duration, and the number of days between surgery and
The mean duration of KHT treatment before the secondary pain acupuncture intervention were explored as possible confounding
assessment was 11.17 min (SD = 7.26 min; range = 5–40 min). factors. Each of these could reasonably have influenced pain report
Patients were sent home with the aluminum discs in place on as measured in the current design. There were no statistically
the right middle finger. There were no complications or adverse significant correlations or other observable associations between
events from the KHT intervention. these factors and any changes in pain reports. These current
findings though statistically inconclusive and based on a limited
2.4. Measuring the duration of KHT benefit research design – at the very least did not support the hypothesis
that these factors were influencing the change reports. These
Patients who had KHT were asked to return after the 10-day outcomes also complemented the results of the previous study by
recovery period and the patient or parents were queried as to how Ochi [1] using traditional acupuncture. That study, though
long (in hours, days or weeks) the acupuncture treatment was of similarly limited in size and design, also failed to support these
benefit. This time estimate was converted to hours if needed and factors as confounds. The factors were excluded from further
recorded. analysis in the current report.
One additional concern was that patients who participated in
the follow-up report – where we asked how long KHT benefit was
3. Results observed – might have been a biased sample. As described above,
only 19 of the 29 patients who received KHT participated in the
All data analysis and data visualization was completed using
the statistical programming language R [10] and the IDE RStudio
[11]. Visualizations were built using the R package ggplot2 [12].
As noted, 29 patients (excluding one 18-year-old) presented for
pain relief after tonsillectomy and reported some level of pain.
These patients were offered KHT. One hundred percent of patients
(29 of 29) who were offered KHT accepted the intervention – none
were opposed to receiving the treatment. In these 29 patients, the
mean reported pain level before KHT was 5.03 (SD = 2.69) out of 10.
This fell to 3.06 (SD = 3.15) after KHT. See Figs. 4 and 5 for a visual
summary of the change in reported pain level before and after KHT.

Fig. 4. Histograms showing the distribution of child pain ratings before and after
KHT therapy, along with a histogram showing the distribution of changes in pain
ratings from before to after KHT. The dotted line is the distribution median. The
Fig. 3. Diagram showing KHT points used in this study. All patients had KHT done to dashed line is the mean. Where it appears there is only one line, the two lines are
their right middle finger only. overlapping.
1266 J.W. Ochi / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1263–1267

KHT on day 8, they could have a maximum of 48 h of benefit (the

full day 9 and 10). This restriction on estimates was implemented
to minimize the extent to which patients conflated acupuncture
pain relief with the relief expected to occur during the natural
healing process.
The mean duration of perceived KHT benefit was 78.20 h (a
little over 3 days), though the standard deviation was large
(64.38 h or just over 2.5 days). The average reported duration of
benefit was significantly different from a duration of 0 (single
sample t = 4.70, df = 14, p < 0.01) with the 95% confidence interval
for the average duration going from 42.55 h to 113.85 h. Three of
fifteen (20%) participating KHT recipients reported 12 h benefit or
less, three of fifteen (20%) reported between 12 and 48 h, and nine
of fifteen (60%) reported more than 48 h of benefit.

Fig. 5. Individual and group trends in reported level of pain before and after Korean
Hand Therapy treatment. The mean and median trends have been given a distinct
4. Discussion
line compared to individual trends. There appear to be fewer lines than total KHT
recipients because some patients had identical starting and ending pain values. This retrospective chart review suggests that the application of
Korean Hand Therapy after tonsillectomy is associated with
decreased pain in children. These results expand on our previous
follow-up (with four being excluded due reporting a duration research [1] in two ways. First, the results suggest that KHT and
when they did not report an initial benefit). This is a reasonable traditional acupuncture may be both associated with pain relief
concern that the current design cannot rule out entirely. However, when treating young patients post-tonsillectomy. Our previous
it is worth noting that there was no correlation (r = 0.36, p = 0.83) study estimated that traditional acupuncture was associated with
observed between amount of benefit and reported duration. In decrease in reported pain level of 2.70–4.49 pain units (95%
other words, the patients who did participate did not seem biased confidence interval) whereas the current study estimates that KHT
to report longer durations if they experienced more pain relief. It was associated with a decrease of 1.19–2.77 units (95% confidence
also seems unlikely that patients would be more likely to interval). Second, the results suggest that KHT may be more widely
participate if they had a positive experience versus a negative accepted by young patients than traditional acupuncture: roughly
experience. In other words, systematic attrition cannot be ruled 21% of patients refused traditional acupuncture in the previous
out but there are no strong reasons to believe that this attrition study but no patients refused KHT in the current study. Combined,
would favor the study hypotheses. these points support the hypothesis that KHT is a viable alternative
for reducing pain relief in children post-tonsillectomy.
3.2. Primary analyses These results align well with other studies of KHT as an
intervention for post-operative relief. A double-blind, randomized,
Changes in pain reports were examined using a dependent placebo-controlled study showed significantly less postoperative
samples t-test and reached statistical significance, t(28) = 5.13, vomiting in children undergoing strabismus surgery; no mention
p < 0.01. Statistical significance suggests that the current sample is is made of any patients refusing KHT during this study [13]. In
unlikely to be observed under the null hypothesis (i.e., that the another randomized, double-blind placebo-controlled trial
reported pain level did not change). Under these circumstances it patients undergoing KHT experienced significantly less throat
seems appropriate to treat this statistical evidence as an indication pain from intubation compared to controls [14].
that the trend of a decline in pain scores observed in our sample is If the results of present study are corroborated, KHT may also
likely to generalize to our sample population. carry additional benefits over and above its association with pain
The mean change in reported pain level was a decrease of 1.98 relief. Traditional acupuncture in the hands of a well-trained
units (SD = 2.08). Though the sample mean is a commonly reported practitioner is very safe with a risk profile comparable to
estimate of effect magnitude, it can easily mislead the reader for prescribing penicillin [15]. Korean Hand Therapy is an even safer
two reasons: (1) it fails to capture the uncertainty associated with procedure because it can be done quickly, effectively and
estimate; and (2) it is not scaled to be easy to compare with other efficiently and does not require needles. The author has not been
effect sizes. Three additional estimates of effect size were selected able to identify any complications or adverse side effects from KHT
to counter these shortcomings. First we determined the confidence in the medical literature.
interval for the mean change in pain report: 95% CI [1.19, 2.77]. KHT also compares extremely favorably to new technology-
Second we examined the breakdown of pain score differences: One assisted surgical instruments developed to reduce tissue trauma
child (about 3% of the sample) reported an increase in pain, six and subsequent pain. The harmonic scalpel [16] and coblator [17]
(about 21%) reported no change, eighteen (about 62%) reported at each increase the cost per patient by about $150.00 but do not
least two units of pain reduction, and eight (about 28%) reported result in less pain [18]. In comparison, each of the KHT stickers
three or more units of pain reduction. Finally we calculated the used in this study cost about 10 cents. Furthermore, since there are
standard measure of effect size for a dependent samples t-test: no needles involved with KHT, patients could even be given a
r2 = 0.48. The collection of estimates suggests that, at least based supply of replacement stickers to be applied at home to hopefully
on the available sample, KHT had a meaningful impact on pain extend the duration of benefit.
reports. The barrier to introducing KHT into practice is also not
Also of interest is how long the effect of KHT lasted for those unreasonable. Most states allow allopathic and osteopathic
patients whose pain scores changed after the KHT intervention. As physicians to practice acupuncture under the authority of their
noted above, 15 estimates of KHT benefit duration were obtained. medical licenses. Physicians who are interested in traditional
All patient estimates were converted to hours and ‘‘capped’’ by the acupuncture, which is the foundation upon which KHT is based,
tonsillectomy recovery window. The natural recovery window for should choose from courses endorsed by the American Academy of
tonsillectomy is 10 days [3]. So, for example, if a patient received Medical Acupuncture [19].
 J.W. Ochi / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1263–1267 1267

It is also worth noting that KHT is but one of many acupuncture Authors’ information
techniques. The patients in this study had only KHT done to avoid
mixing the results of various acupuncture methods. However, the Dr. James Ochi is a fellowship-trained pediatric otolaryngolo-
author has anecdotally observed in his own practice that KHT can gist board-certified in both Otolaryngology and Medical Acupunc-
be easily combined with traditional acupuncture if desired to ture. He is a Voluntary Assistant Clinical Professor of Surgery at UC
further reduce throat pain and relieve nasal congestion or San Diego School of Medicine in San Diego, CA.
headache. In other words, the author hypothesizes that the
magnitudes of pain relief observed in the current study of KHT and Acknowledgments
previous study of traditional acupuncture [1] may be increased by
combinations of techniques. The author is very grateful for the expertise contributed by Yue-
Our study was limited to children undergoing KHT for pain Pang Mok MD in selecting the Korean Hand Therapy points used in
relief but many adults also undergo tonsillectomy and often this study. The author is also indebted to Brian Waismeyer MA and
endure pain for a much longer time postoperatively. The recovery Fraser Cocks PhD for their time and expertise.
period is about 10 days in children. Over half of adults however in
one study had pain up to 3 weeks postoperatively [20], suggesting References
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