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Comforting Clients with Postherpetic Neuralgia
Pathology Perspectives

By Ruth Werner

Originally published in Massage Bodywork magazine, June/July 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.

Imagine that one day you wake up and, to your profound relief, you find your shingles infection, which had created painful, itchy blisters all along a wide stripe of your rib cage, has healed and disappeared. The blisters only lasted a couple of weeks, but during that time any kind of touch, breeze, or change in temperature could send you through the roof with pain. You literally felt like jumping out of your skin. Such freedom to be done with this.

Unfortunately, no one told the sensory neurons in your skin that the infection is now over. The pain persists. It itches; it burns; it cuts like a knife. The severity fluctuates, but the pain is constant--even though the skin has completely healed. What in the world is happening? This is a condition called postherpetic neuralgia (PHN), and it affects nearly one-fifth of the million people who have shingles in this country every year (about 200,000 people).
To talk about PHN, we need to look briefly at the problem that precedes it--herpes zoster, which is also called shingles. And to discuss shingles, we need to go back to where the whole episode began--chicken pox.


Chicken Pox and Shingles
Most people born in the United States before 1995 were exposed to chicken pox sometime in early childhood. For most of us, that infection took the form of itchy blisters on a red base. This is the hallmark of any herpes infection of the skin, and chicken pox is a member of that viral family. The lesions lasted a few days and then resolved, usually without incident or complication.

But the end of the chicken pox is just the beginning of the story. Unlike most pathogens, when we fight off chicken pox, the virus (called varicella zoster) is never fully expelled from the body. It goes into hiding somewhere in the dorsal root ganglia of the spinal cord, or in the ganglia of the trigeminal or facial nerves. There it waits for the immune system to give it another chance to rebloom. Sometimes a recurrence of varicella zoster is just another bout of chicken pox. But more often if the virus reactivates, it comes back as shingles.

An outbreak of shingles typically lasts two to four weeks. It is often preceded by a prodrome stage, which could involve two or three days of pain or tingling at the affected dermatome, fever, nausea, and general malaise. Then, the virus moves down the nerve from the ganglion where it slept and ultimately attacks the sensory dendrites in the skin. This results in acutely painful blisters that clearly mark the dermatome of the affected nerve root. T3, T4, and the ophthalmic branch of the trigeminal nerve are the areas most commonly affected. When shingles affects the trigeminal nerve, the eye may sustain permanent damage. When it affects the facial nerve, painful blisters may accompany a sudden onset of facial paralysis that resembles Bell's palsy; this is called Ramsay-Hunt syndrome.

Blisters usually last for a few weeks and then crust over and disappear. Risk factors for developing shingles, beyond an earlier exposure to chicken pox, include age (it is rare in people under 50 years old) and any kind of immune system suppression. This can include congenital immune problems, medications that curb immune system activity (chemotherapy, drugs to inhibit tissue rejection, steroidal anti-inflammatories, and others), any kind of lymphoma, and infection with HIV. It is important to point out that the blisters associated with shingles carry a high viral load, but anyone who has been exposed to chicken pox has protection from this pathogen.


Who Gets PHN?
Shingles is an unpleasant viral inflammation, affecting mostly people who are already weakened from other challenges. But to have the pain of shingles persist even after the blisters heal seems particularly obnoxious. PHN is identified when the pain lasts a month or longer after the shingles blisters have healed. It is estimated that up to 20 percent of the million or so people in the United States who have shingles each year develop PHN. Six months later, up to a quarter of those who developed PHN still have it. And a year or more later, up to 5 percent of the people who developed PHN still have pain.

The major factor that seems to influence whether or not a person develops PHN is age: the older the person is when shingles develops, the more likely he or she is to have PHN. PHN is diagnosed in 60 percent of the people who have shingles at age 60, and in 75 percent of the people diagnosed at age 70. Some research suggests an increased risk of PHN if shingles is not treated with antiviral medication within the first few days of symptoms, but this is not universally accepted.


What Causes PHN?
The exact cause of PHN pain is not well understood. Some people suggest that varicella-attenuated T cells continue to attack Schwann cells on the sensory neurons even after the virus subsides; this would classify PHN as an autoimmune disorder. Others propose that new pain-related connections are formed in the spinal cord as a result of viral activity. It is also possible that pain-inhibiting connections are destroyed by the infection, while new excitatory connections develop in response to inflammation. One problem with not having a clear picture of the source of the pain is that it is difficult to interrupt the disease process. PHN is notoriously difficult to treat.


Prevention
Studies of elderly people who spend time with children who have chicken pox show that they may have increased resistance to the virus. This makes sense: exposure to varicella requires a protective response, so the number of T cells to fight the virus increases. This evidence suggests the possibility that vaccinating elderly people against chicken pox may strengthen their resistance to the virus, thus reducing the risk of shingles and of course of PHN as well. (A chicken pox vaccine for young children was made available in 1995.) However, this strategy is still under investigation and is not the established practice at this time.


Treatment
The good news about PHN is that for most people it eventually resolves on its own. The bad news is that this may take months or years, and the longer the symptoms are present, the less likely it is that recovery will be full. When PHN is long-term and intense, many people pursue a multidisciplinary treatment approach with pain specialists, psychiatrists, and other professionals working with a primary care provider for the best possible outcome.

Treatment options for PHN range from gentle to extreme. Experts agree it is important to interrupt the pain cycle as soon as possible. The first step in treating PHN is to try to prevent it. Right now this means treating shingles with antiviral medications as quickly as possible. If these are administered within seventy-two hours of the onset of shingles blisters, they can shorten the duration of the infection and may reduce the possibility of PHN.
PHN that has been present for less than a few weeks may be interrupted with simple analgesics or cold packs. Some people report success with topical applications of tea tree oil, apple cider vinegar, mentholated ointments, skin coolants, and topical aspirin at this stage, but these interventions are not well researched at this point.

Some topical applications have been more thoroughly explored, however. A salve made with capsaicin (the chemical that gives hot peppers their "heat") limits pain sensation by decreasing substance P (a pain-related neurotransmitter) at nerve endings. This cream must be applied several times a day to be effective, and the burning sensation it causes is too intense for some patients, so it is not appropriate for everyone. Lidocaine patches are another topical application that is successful for many patients, especially when the PHN has not been present for a long time. These patches have a low risk of side effects and are often useful to decrease, if not eradicate, the pain of PHN.

When topical applications are not sufficient to limit PHN symptoms, pharmacological interventions must be considered. Low-dose tricyclic antidepressants are well established to limit PHN pain by blocking the reuptake of norepinephrine, but they carry risks for interactions with other drugs. When a patient is elderly and takes medication to manage a variety of problems, tricyclics may cause dangerous side effects including dizziness, orthostatic hypotension, and digestive problems. Antiseizure medication is another option. Many patients report good success with managing PHN this way, but side effects include sleepiness and dizziness. This may also exacerbate dementia or loss of cognition in elderly patients.
Other interventions for PHN include intrathecal doses of corticosteroids (the anti-inflammatory is injected directly into the spinal canal), opioid drugs, transcutaneous electrical stimulation devices (TENS machines), or various surgical options to block pain transmission. Sadly, none of these has a proven track record for improving symptoms.

Patients who experience prolonged PHN symptoms may pursue alternative options instead of or in addition to their allopathic healthcare. These options may include hypnosis, acupuncture, and cognitive behavioral therapy to help establish some effective coping mechanisms. The pain of PHN can impact much more than the skin of the affected person. It can interrupt concentration, interfere with physical activity, ruin sleep, and cause deep and dangerous depression. While most cases of PHN eventually clear up without intervention, it is important to shorten the duration of this miserable condition as much as possible.

Vigorous massage is obviously not a practical intervention at the site of post-shingles pain, although some clients may appreciate a cooling, gentle, nonmoving touch over their hyperirritable skin. Furthermore, as these patients struggle with the complications of living in chronic pain (including insomnia, anxiety, and other problems), massage therapists can offer them the chance to experience how much of their body doesn't hurt. If a person with PHN can be comfortable on a table, massage of any modality that stays within pain tolerance may support better sleep, less anxiety, and an overall improved quality of life. When a massage therapist weighs risks and benefits for a client with PHN, it is clear that risks are easily avoided while benefits are substantial. Get to work!

Ruth Werner is a writer and educator for massage therapists. She teaches several courses at the Myotherapy College of Utah and is
approved by the NCTMB as a provider of continuing education. She
wrote
A Massage Therapist's Guide to Pathology (Lippincott, Williams Wilkins, 2005), now in its third edition, which is used in massage
schools all over the world. Werner is available at www.ruthwerner.com
or wernerworkshops@ruthwerner.com.



Resources
American Accreditation HealthCare Commission. Shingles and chickenpox (varicella-zoster virus). About.com. http://adam.about.com/reports/000082_8.htm (accessed March 20, 2006).
eVitamins.com 1999-2006. Shingles and postherpetic neuralgia. www.evitamins.com/healthnotes.asp?ContentID=1272002.
Loeser, John D., MD. Surgical options for treating postherpetic neuralgia. The Center for Shingles and Postherpetic Neuralgia. http://shingles.mgh.harvard.edu/surgical.htm (accessed March 20, 2006).
McElveen, W Alvin, MD. 1996-2006. Postherpetic neuralgia. WebMD. www.emedicine.com/neuro/topic317.htm.
Pilot, Frances et al. Management of shingles and postherpetic neuralgia. AAFP.org. American Family Physician monograph. www.aafp.org/PreBuilt/afpmonograph_shingles.pdf (accessed March 20, 2006).
Stankus, Seth John, MAJ, MC et al. 2000. Management of herpes zoster (shingles) and postherpetic neuralgia. American Family Physician, April 15. www.aafp.org/afp/20000415/2437.html.
StopPain.org, Department of Pain Medicine and Palliative Care. 2005. Shingles. Continuum Health Partners, Inc. www.stoppain.org/pain_medicine/content/chronicpain/shingles.asp.
VZV Research Foundation. Postherpetic neuralgia. www.vzvfoundation.org/phn.html (accessed March 20, 2006).




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