An Integrative Approach for Treating Postherpetic Neuralgia?A Case Report

Postherpetic neuralgia: case study of class 4 laser therapy intervention

OBJECTIVE

Postherpetic neuralgia (PHN) is a neuropathic sequelae in 8% to 27% of individuals with prior varicella zoster virus infection and herpes zoster resulting in retrograde demyelination, neurotoxic reactive oxygen species levels, and proinflammatory cytokine activation of microglia. Pain management strategies are well documented, but not always effective. Laser therapy has shown utility in nerve injury-related pain disorders and was considered a potentially efficacious intervention.

DESIGN

Case report.

METHODS

Class 4 therapeutic laser treatment was applied with a dual wavelength GaAlAs (810 nm), GaAl (980 nm) laser, 2 to 4 W, 50% duty cycle, 10 Hz pulse active phase, 2.5 cm diameter aperture, scanning technique with skin contact, 10-minute treatment, 600 to 1200 J total, energy density of 3.5 to 7.1 J/cm average per session, and power density from 0.41 to 0.82 W/cm for 8 treatments. Outcome measures included the Neuropathy Pain Scale Questionnaire as the primary outcome measure, with the Numeric Pain Scale and total area of allodynia touch sensitivity as secondary outcome measurements.

RESULTS

The author reports a case of PHN of 15-year duration resistant to prior interventions. Weekly laser therapy treatment over 8 weeks resulted in reduced 0 to 10 Numeric Pain Scale score from 8 to 0, Neuropathy Pain Scale Questionnaire total score from 39 to 4, and allodynia over a 60 cm surface area of the upper trunk and posterior arm totally resolved, with resolution continued at 14-month follow-up.

DISCUSSION

Theoretically, laser therapy induced tissue changes in this case occurring at and below the skin surface altering inflammatory and excitatory peripheral mechanisms noted to take place in the PHN patient. Peripheral nociceptor firing must be brought back to normal thresholds to resolve such chronic neuropathic pain and inhibit the possible central sensitization component. Anti-inflammatory cytokines, growth factors, nitric oxide, adenosine triphosphate (ATP), and other mechanisms stimulated by laser therapy as noted in medical literature may be central to the favorable response seen in this patient. Controlled clinical trials of class 4 laser therapy in the PHN patient population with similar doses would be beneficial to determine if this is an effective treatment option in PHN.

Neuropathic pain other than CRPS in children and adolescents: incidence, referral, clinical characteristics, management, and clinical outcomes

BACKGROUND AND OBJECTIVES

Chronic pain in children and adolescents is common, but proportion of neuropathic pain (NP), a heterogeneous group of diseases with major impact on health-related quality of life, significant economic burden, and limited treatment options, is unclear. Many studies have focused only on complex regional pain syndrome (CRPS). Our aim was to examine the incidence, clinical features, management, and outcome of non-CRPS NP in patients referred to a chronic pediatric pain clinic (CPPC) at a tertiary-care hospital.

METHODS

Retrospective analyses of the patient's files with non-CRPS NP from 2008 until 2012.

RESULTS

Twenty patients (9.9-22.0 years; 10.7% of new referrals) were treated with non-CRPS NP (postoperative 8/20, trauma-related 5/20, disease-related 7/20). The number of consultations performed and the number of medications used before CPPC were significantly higher than in CPPC (Z = 0.75, P = 0.005; Z = 1.68, P = 0.003; respectively, Wilcoxon test). The number of diagnostic procedures was not statistically significant. Invasive treatments were used in 50% of patients. Full/partial recovery was accomplished in 95%. anova with repeated measures yielded a highly significant difference between the initial and final visual analog scale (VAS) scores (8.2 ± 1.3; 1.19 ± 2.01, respectively; P < 0.001), and no effect of age, gender, time needed for referral to CPPC, and patient's categories on the change in VAS.

CONCLUSIONS

Better understanding of the medical profile of pediatric patients with non-CRPS NP is crucial to timely and correct diagnosis and effective management, but even children with delayed diagnosis still have a good outcome. The management of this condition by an experienced team is recommended.

Neuropathic pain in children: Special considerations

Neuropathic pain is relatively uncommon in children. Although some syndromes closely resemble those found in adults, the incidence and course of the condition can vary substantially in children, depending on developmental status and contextual factors. There are some neuropathic pain syndromes that are rare and relatively unique to the pediatric population. This article discusses the array of neuropathic pain conditions in children and available treatment strategies. Data are limited by small numbers and few randomized controlled trials. Research and clinical implications are discussed.