Post-herpetic Neuralgia Treatment

 

Post-herpetic neuralgia, or the excruciating pain that persists after an attack of shingles, is a condition in which patients are often at their wits end after having tried many therapies. The pain is actually classified as a "neuropathic pain" - which simply means that the pain source is due to the nerves, as opposed to a muscular, joint, or bone structure.

 

Post-herpetic neuralgia, or colloquially speaking shingles pain, is the result of an infection with acute herpes zoster. It does not always happen, and most people will get over their acute shingles pain without having the pain syndrome that can persist long term after the original shingles lesions are gone. The acute herpes infection usually manifests as a painful rash on one area of the body, on one side only. In fact, it follows the "dermatone" of a nerve. That affected nerve can persistently cause pain by leaking substance P after the infection is over, giving rise to post shingles pain.

 

We do not know what makes some people more susceptible to having post-herpetic neuralgia after a shingles infection. There is some evidence that patients who have an immune system that is somewhat compromised may be at increased risk. This might include the elderly, or those with other chronic illnesses.

 

Some doctors have tried antiviral prescriptions to prevent post shingles pain.  Such antivirals may reduce the duration of the acute shingles (with the rash) - but it is not clear that they reduce the chances of post shingles pain. They likely are not useful when post shingles pain has already set in.

 

An antidepressant (older tricyclic class of drug) has been shown to reduce the chances of getting post shingles pain, and if someone is in the acute phase you might want to discuss this with your naturopathic physician or family doctor.

What treatment, other than drugs, can be used if a patient already has post shingles pain?

 

Acupuncture is the first treatment that I typically try in my patients. If there is not significant relief, that persists, after the first two treatments, then I would typically more on to a more aggressive treatment. There really is not any point in having pain for longer than necessary, and treatments need to give persistent relief.

 

A nerve block with lidocaine can give temporary relief, at least until the local anesthetic wears off. Interestingly, I have had a few patients who have had persistent relief with one or two treatments, but I usually add in homeopathic medications that support the healing of the nerve, and drainage of toxins out of the connective tissue around the nerve. Such homeopathics include Traumeel, Zeel, and especially methyl B12.

 

Agents that decrease substance P (a chemical that causes pain) may be useful. Depletion of substance P from the affected nerve will make less of it available for the post shingles pain syndrome. This is usually not a first line treatment as some patients will find that it aggravate the pain (temporarily) without improving it.

 

My approach

 

Well, borrowed, actually.

 

I came across a great study that combines the above treatments for post shingles pain. The study was published by a doctor in Brazil (far from Vancouver!) and studied a total of 55 patients who had failed conventional therapy for post singles pain. Amazingly, the doctor found that 70% of these patients had an improvement of between 75% to 100% reduction in pain. Remember these patients had undergone conventional drug therapy, physical medicine, and even electrotherapy. They had tried local anesthetic injections, and acupuncture, without any relief at all. That makes this therapy all the more intriguing.

 

This doctor used a therapy that I have been using for mostly chronic fatigue syndrome andcardiovascular patients - ozone therapy!

The treatment

 

Dr Heinz Konrad published the post shingles pain article with his treatment protocol:

 

a) 9 mg of ozone, given rigorously within the technique of the major auto-hemotherapy, two or three times per week. This is basically very similar to a typical IV treatment. I take about half a pint of blood through an IV line into a sterile, single use container and anticoagulate it with heparin. Ozone is then added and mixed, and the blood is reinfused in one closed circuit.

 

b) injections of 5 ml of a local anesthetic into nerve exit points or nerve trajectory areas related to the affected skin area, two or three times per week. I usually do this at the same time, or at the end of the ozone treatment. Typically I would use acupuncture needles first, as the injections take a few seconds and the ozone treatment itself takes about 30-40 minutes anyway. That way, during the ozone treatment the patient is getting acupuncture done as well.

 

c) IM injection of Magnesium, two or three times per week ( Mg Levulinate 40 mg, Mg Sulphate 640 mg ). Again, done at the end of the ozone treatment.

 

d) prescription of 2 mg Lorazepam tablets, to be taken at night, only when sleep was impossible. Typically natural sleep aids would be tried first, such as melatonin or valerian. But I have never had to address the sleep issue in my patients.

 

The average number of treatments was 14 in Dr Konrad's Brazilian study, which is similar to my post shingles pain experiences in Vancouver. Dr Konrad had a range of treatment necessary from a minimum of two, to a maximum of eighty. The average length of the treatment course was 2.5 months.

Why does it work so well?

 

We can only postulate as to why ozone therapy can be so effective in pain relief. My own experiences with using ozone in musculoskeletal and joint pain suggest that ozone is extremely effective. In those cases though, the ozone is applied directly into the area of pain, and stimulates a release of chemicals that promote healing. In this naturopathic therapy for post shingles pain, the ozone is applied to the blood, giving a whole body or global treatment.

 

Dr Konrad suggests in his article that ozone therapy may promote the release of endorphins, but this would only suggest temporary relief, which was not the case. Dr Konrad does further suggest that perhaps "pain memory" might be altered by the ozone therapy induced endorphin relesae.

 

Inflammation is generally reduced overall with ozone therapy, and this may be an important mechanism. Dr Konrad also suggests that the well-known and well-researched improvements in oxygenation and blood flow may be responsible, as this would be supportive of the body's natural ability to self-regulate. Remember, most people do not get the post shingles pain syndrome, and that those that do may be somewhat compromised in health to begin with.

 

Yes, the study was not double-blinded, and magnesium injections as well as local anesthetic injections were used, and there was no control group. But remember, a placebo effect typically comes with early treatments, and these patients had tried multiple conventional and alternative therapies prior to ozone therapy. Further, a placebo effect typically wears off over time, and has greatest effect when a therapy is started. This was not the case in this study.

 

So how do I get started?

 

Being a local, Vancouver naturopathic physician, I can only speak of regulatory policies in BC. In BC, you would want to find a naturopathic physician who is certified in ozone therapy, and who can provide major autohemotherapy. Obviously I am one, but if you are not within the Vancouver area then you might try going to the BCNA to find a referral to a doctor who is certified in ozone therapy. Doctors generally charge around $100-$150 per ozone treatment.

 

I do get a lot of emails from patients who are willing to travel for ozone therapy, and my receptionist has a list of local hotels that are reasonably priced. Given that the average duration of treatment is about 2.5 months though, I would try finding a physician locally (MD or ND) who provides ozone therapy. They can typically be found by searching the ACAM (American Academy for Advancement in Medicine) database. If a patient is travelling from out of town, I do try to make the treatments more frequent, and will often treat 5 times a week instead of twice, for an average of 2 weeks. I have not tried this frequency in post shingles pain, though it would be safe as I get good success with other conditions at this frequency.