Postherpetic Neuralgia Pain and Laser Acupuncture

Background, diagnosis, discussion, and case report of successful management of postherpetic neuralgia pain in an elderly patient using laser acupuncture.
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Last month I wrote about the use of therapeutic laser for acupoint stimulation (laserpuncture). In this issue, Dr. John Stump et al shares an example of using laserpuncture in clinical practice. He presents a case of post-herpetic neuralgia that he treated with laserpuncture. This article should help further the practitioner’s level of understanding related to the use of therapeutic laser for acupoint stimulation.

William J. Kneebone, CRNA, DC, CNC, DIHom

According to the American Society of Regional Anesthesia, post-herpetic is the leading cause of suicide in chronic pain patients over the age of 70 years.1 This case study reviews the results of using a laser as a viable method to control post-herpetic neuralgia pain, known to be a difficult case to manage. This elderly man had suffered severe pain for nearly one year and had contemplated suicide. The improvement began to show dramatically after the fourth treatment. After a course of 12 treatments, he reported no further intense pain in the previously involved area. Since manageability of post-herpetic neuralgia has been considered effective only in younger patients with duration of pain less than six months, this case study may be of benefit for those treating post-herpetic neuralgia in older patients.

Herpes zoster, also known as “shingles,” is an infectious viral disease commonly encountered in clinical practice. It is usually a benign self-limiting condition but the potentially serious complications of post-herpetic neuralgia, ocular involvement, and the confusing therapeutic regimens that are often advocated, make this a complicated condition.

When typical in presentation, herpes zoster is not difficult to diagnose (See Tables 1 and 2). Early in the course, watery vesicles appear on an erythematous base following the cutaneous distribution of one or more posterior root ganglia, usually on the trunk of the body, and spread unilaterally. A dermatomal pain, itching or paresthesias may follow this. In uncomplicated cases of herpes zoster, the skin lesions will crust and fall off with in two to three weeks.

In a certain percentage of the population, the lesions of the herpes zoster resolve but the pain persists and, in some cases, actually gets worse. The involved zone may develop severe and prolonged burning pain with occasional “fire-like” stabs of pain. This protracted pain is known as “post-herpetic neuralgia,” one of the severe chronic pain syndromes.

The significance of this condition lies in the fact that it is one of the most frequently encountered problems among pain management professionals.1 This is especially true in the elderly, who have a higher incidence of excruciating, unrelenting pain long after the acute illness has resolved. Its intensity and duration create such a suffering that many consider suicide as a means of escaping its ravages. The overall incidence of post-herpetic neuralgia is estimated to occur in 18 to 35 percent of all herpes zoster victims but may rise to more than 50 percent among elderly patients.2,3

Table 1. Herpes zoster
essentials of diagnosis
  1. Unilateral painful vesicles in a dermatomal distribution
  2. Rarely, unilateral erythematous plaques without vesicles
  3. Inclusion of herpes zoster in the differential diagnosis of unilateral pains
  4. Multinucleated giant cells on cytological studies
  5. Definitive diagnosis and differentiation from herpes simplex infection (dependent on viral culture)
Table 2. Herpes zoster differential diagnosis
  1. Zosteriform herpes simplex
  2. Chickenpox and other viral exanthema
  3. Contact dermatitis
  4. Dermatitis herpetiformis
  5. Cellulitis
  6. Factitious ulcer or dermatitis

While the severity of the pain should be considered in the definition of post-herpetic neuralgia, duration of the pain is often the only defining criteria. Some authors consider pain persisting more than four weeks after the resolution of the lesions to be diagnostic of post-herpetic neuralgia. Others have considered the minimum duration to be 2,3,6, 12, or 24 months.4

Our clinic has managed over one hundred cases since our initial 1994 study and investigation of post-herpetic neuralgia.5 However, the last twenty-five cases over the past three years have been treated differently. Up until that time, electro-acupuncture was viewed as the most efficient and viable method in relieving a patient’s pain due to post-herpetic neuralgia. Within the past three years, we have changed our protocol to include laser treatment. In 2003, we began using a Luminex 500 laser. At that time we were not convinced of its effectiveness as compared to the electro-acupuncture which had been used in our clinics for over 25 years. We did a clinical study to investigate its effectiveness in our most persistent chronic pain6 cases and, in 2006, the results were published in the Journal of the American Academy of Medical Acupuncture.7

Case Report

Dr. I, an 89-year-old male and former practicing physician was referred for evaluation and treatment of pain from post-herpetic neuralgia—for which he had received medical diagnoses and treatment over one year with no success. He was Caucasian, not over-weight, and had several outstanding complications at the time: active heart trouble, impaired hearing, and a pacemaker. The lesions were distributed on his left side at the thoracic level of T6-7-8 and going around to the sternum. They had cleared up in the usual two to three week period following appearance of the lesions, medical care, and beginning prescribed medications (acyclovir and zovirax).

Figure 1. Dr. I, receiving Luminex Laser treatment for PHN.

However, the pain associated with the original lesions never subsided. It had begun with a continual ache, burning, and superficial pain that progressed in severity over the following months in the same dermatomal distribution, T6-7-8. For this complaint he had receive several pain medications—neurontin and hydro-codone—in addition to the original medications. Under medical care, his condition did not improve after one year from the onset of herpes zoster. Due to his heart condition and age more aggressive treatment was not considered. His medical doctor now agreed to try our conservative alternative treatment.

At the time he was first seen in our clinic, the pain was constant and extremely severe, described as ‘11’ on a 10-point scale of intensity. The patient could not be touched in the area, could not sleep regularly, and was heavily medicated for pain reduction. No formal assessment of the patient’s chronic pain had been made since the beginning of medical care.

Upon examination, the patient’s posture was slightly kypothic and away from the painful left side. He had a continuous aching and burning and superficial pain associated with hyperpathia and dysesthesia. This was dramatically increased by light touch to the area. There was a feeling of constriction or tightness along the affected area associated with itching and a feeling of formication. Episodic pains shooting out in a radicular pattern corresponding to the affected dermatome accompanied these symp-toms. There was no definite daily pattern, but symptoms did seem to worsen at night.

First published on: June 1, 2008