COLD LASER THERAPY

Treatment of Postherpetic Neuralgia With Low Level Laser Therapy

Author: Fred Kahn MD, FRCS (C)
Source: Meditech International Inc.

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Herpes zoster, also known as shingles, produces a painful vesicular rash that results from the reactivation of the varicella zoster virus (VZV), the virus that originally causes chickenpox. Although the rash typically resolves over the course of 4 to 5 weeks, the pain may persist for months, or even years, after the rash has disappeared. Known as PHN, this phenomenon can often be debilitating to the patient. A number of different treatment options are available to clinicians, including pharmaceuticals, nerve block injections, and physiotherapy, but unfortunately no single therapy is 100% effective at reducing PHN.1,2 LLLT is a noninvasive, pain-free, light-based therapy that uses red and infrared light to resolve the inflammatory process and eliminate pain in patients with PHN. We present a number of PHN cases that have responded favorably to LLLT and review the mechanisms of action of the technology.

Background

The VZV is a linear, double-stranded DNA virus that causes two pathological manifestations. Initial infection with the virus, usually during childhood, may result in chickenpox. The virus then migrates to a dorsal root ganglion, where it can remain latent indefinitely (Figure 1). Later in life, immune system depression or stress can trigger a reactivation of the herpes zoster virus. The lifetime risk of developing herpes zoster is approximately 30%.3,4 An estimated 1 million new cases of herpes zoster occur each year in the United States,5 resulting in 50,000 to 60,000 hospitalizations. On occasion, the disease can lead to loss of bladder or bowel control and may even be fatal.

603-f1
The incidence and severity of herpes zoster has been shown to increase with advancing age.5 Individuals over the age of 60 years make up approximately 40% to 50% of the 1 million new cases that occur each year. The increased risk of herpes zoster with advancing age is thought to be caused in part by immunosenescence, the gradual deterioration of the immune system that is part of the natural aging process. In addition, patients who are immunocompromised have a greater chance of manifesting the disease, with increased severity of symptoms.6

Herpes zoster is characterized by a unilateral vesicular eruption in a dermatomal distribution, most commonly over the trunk and cranial regions. Initial symptoms prior to the appearance of a rash include headache, pain, malaise, and acute photophobia. The rash itself may be accompanied by pruritus, altered sensitivity to touch, or allodynia. Initially, the maculopapular rash is characterized by varying degrees of inflammation, and it progresses to take the form of coalescing clusters of clear vesicles containing high concentrations of VZV.4

PHN is a common complication of herpes zoster that affects 50% of individuals over the age of 50 years who develop shingles. PHN is characterized by ongoing pain subsequent to the resolution of the rash associated with this disease. The pain has been described as an unrelenting sharp, burning, stabbing symptom that interferes with sleep, work, and other activities of daily life. It can lead to social withdrawal and depression.2 The duration of PHN can last from 30 days to long after the disappearance of the dermatological lesions. In some cases, the pain persists for many years.7

As shown in Figure 1, PHN results in inflammation of the sensory root ganglia, the dermis of the associated dermatome, and frequently, the posterior and anterior horns of the grey matter, meninges, and both dorsal and ventral nerve roots.

LLLT Treatment

For more than 40 years, LLLT has been effectively used in the treatment of wounds and in acute and chronic musculoskeletal conditions, including degenerative disc disease, repetitive stress injuries, muscle strains, and arthritis.8 LLLT has been cleared by the FDA for the relief of minor muscle and joint pain, arthritis, muscle spasm, relieving stiffness, and promoting relaxation of muscle tissue. Certain devices have also been approved for treating carpal tunnel syndrome and rotator cuff injuries specifically. The therapy is traditionally not covered by insurance and patients may pay between $30 and $60 per half hour of treatment, depending on the healthcare practitioner. Symptom that interferes with sleep, work, and other activities of daily life. It can lead to social withdrawal and depression.2 The duration of PHN can last from 30 days to long after the disappearance of the dermatological lesions. In some cases, the pain persists for many years.7

LLLT is a noninvasive, pain-free, light-based therapy that uses a combination of red and infrared light in the form of laser and superluminous light-emitting diodes. The power output of these devices is below the level of surgical or other high-intensity lasers. Photon particles of light are absorbed by the mitochondria through cytochrome c oxidase and result in increased cellular adenosine triphosphate levels.8

In the case of neuropathic pain, LLLT has been proposed to mediate analgesia by releasing local neurotransmitters such as serotonin,9 promoting the release of endorphins,10 while simultaneously decreasing prostaglandin E2 and bradykinin levels. An increase in anti-inflammatory cytokines, interleukin (IL)-10, along with a decrease in pro-inflammatory cytokines, tumor necrosis factor-a, and IL-1b, allows for the rapid resolution of the inflammatory process.11 LLLT has been well documented to stimulate tissue regeneration including angiogenesis, collagen production, muscle and nerve regeneration, cartilage production, and even bone formation.8 The inflammation that causes the abnormal stimulation of the nerves in the case of PHN is reduced rapidly with LLLT.

In a double-blind crossover trial of LLLT for PHN, all patients who received treatment demonstrated a reduction in pain severity of between 40% and 95% (mean value, 74%) and a reduction in pain distribution (as measured by body surface perimetry using a universal goniometer) of 49% to 84% (mean value, 64%).12 Patients all began with a pain level of 10 out of 10, as measured on the visual analogue scale (VAS)—with 0 representing no pain, 2 – mild pain, 4 – moderate pain, 6 – severe pain, 8 – very severe pain, and 10 – intolerable pain. Therefore, a reduction of 40% to 95% on VAS represents a significant impact on the quality of life of these patients.

603-t1Follow-up of patients between 3 to 6 months after therapy revealed that 80% of the patients had maintained their improvement in pain levels and pain distribution. The large age range of the patients (55 to 82 years) and duration of PHN (6 months to 8 years) could account for the relatively wide range of pain reduction demonstrated in this study. In particular, 50% of the patients were over the age of 70 years, and 25% had suffered from the condition for more than 4 years. A detailed analysis of age and severity of condition compared to treatment response was not presented in the article. Despite this variability, all patients saw an improvement of at least 40%, which is comparable to the most successful pharmacological treatment, but without the harmful side effects (Table 1).

Application of LLLT in PHN

Prior to treatment, pain is measured on VAS. In general, patients presenting with PHN usually categorize their pain at a 9 out of 10, which has a large impact on their quality of life and daily activities. Patients experiencing such a severe level of pain will find a reduction in the VAS scale of 2 to 3 points to be significant, as compared to a patient who begins with a moderate pain level of 4 or 5 out of 10. Patients undergoing LLLT normally notice an immediate improvement in pain of approximately 20% to 30% during the administration of the first 3 treatments. During the course of 10 to 15 treatments, patients usually experience 80% to 90% relief of pain and other symptoms.

LLLT treatment consists of the application of red and infrared superluminous diode arrays and laser probes both to the rash directly and to the spinal nerve root that supplies the sensory nerves to the associated regional dermatome. We used the BioFlex Laser Therapy System (Meditech International Inc., Toronto, Canada), with direct contact over the lesion sites and over the nerve roots involved—at their origin and along the course of the nerve. The following 3-step approach was used for each site:

  1. 660 nm (red), GaAlAs, superluminous diode (SLD) array, pulsed (50 Hz, 50% duty cycle) 10 mW/cm2, 75 cm2, 6 minutes
  2. 840 nm (infrared), GaAlAs, SLD array, pulsed (10 Hz, 60% duty cycle), 20 mW/cm2, 75 cm2, 6 minutes
  3. 830 nm (infrared), GaAlAs, laser diode, 0.1 cm2, continuous wave, 540 mW/cm2, 6 minutes

Treatments can take 18 to 42 minutes depending on the extent of the lesions and affected dermatomes. The treatment program consists of 3 times per week for the first 3 weeks and then is reduced to 2 times per week until the patient is asymptomatic. As noted, treatments are usually not covered by insurance, and patients have to pay out of pocket.

Treatment is noninvasive, has no adverse effects, and no drug interactions. It can be safely administered over metal implants and pacemakers without concern. The use of non-steroidal anti-inflammatory drugs is discouraged as they can mask symptoms and interfere with the effects of treatment, which works to expedite and resolve the inflammatory process, rather than suppress it. The following clinical profiles illustrate the effectiveness of LLLT in the hands of the authors.

Clinical Profiles

Case 1
The patient is a 79-year-old retired veteran who presented with a 10-day-old VZV rash with a left C-5 distribution. Valacyclovir (Valtrex) was prescribed 3 days after onset of shingles. The patient’s pain level was at 9 out of 10 on the VAS despite being prescribed pregabalin (Lyrica, 75 mg every 12 hours) and oxycodone (OxyContin, 15 mg every 4 hours).

Laser therapy treatment was administered directly over the rash and over the spinal ganglia of the fifth cervical spine nerve. No other form of therapy was administered. The patient received 18 LLLT treatments over the course of 2 months. After 10 treatments, the patient’s pain level was reduced to 5 out of 10 on VAS and he was able to reduce his oxycodone usage. As his rash disappeared, the remaining 8 treatments focused on the spinal ganglia until he became completely asymptomatic and all medications were discontinued. The patient remained asymptomatic on follow-up 1 year later.

Case 2
The patient is a 68-year-old musician who presented with a 1-year history of PHN following a severe attack of shingles in the right T6-T7 region. He was prescribed gabapentin (900 mg 3 times per day), but no antivirals. His pain level was at 9 out of 10 when he presented at the clinic and he had not performed musically in more than 1 year.

Laser therapy treatment was administered over the spinal ganglia of the T5-T8 region. No other form of therapy or medication was administered. The patient received 23 LLLT treatments over the course of 2 months. After 10 treatments, his pain level was reduced to 3 out of 10 and he discontinued the use of gabapentin. He continued to receive 13 additional treatments, at which point he was asymptomatic and was able to return to performing music in a normal fashion. The patient remained asymptomatic at 1-year follow-up.

Case 3
The patient is a 51-year-old woman complaining of pain and dermatological manifestations over her right lower back, thigh, and inguinal regions. These were acutely inflamed and demonstrated extensive vesiculopapular- and plaque-type lesions of extensive distribution (Figure 2). Ten days prior to her initial presentation, the patient awoke with severe right lower back pain radiating to the inguinal and thigh areas. The dermatological lesions developed over the subsequent 3 days. The pain was excruciating in degree and required 10 Tylenol tablets per every 24-hour period. These provided only minimal relief. No antivirals had been prescribed.

603-f2The patient initially had 3 laser therapy treatments within the first week, which resulted in a significant reduction in pain and marked diminution of the dermal lesions. No other form of therapy or medication was administered. The patient received 15 treatments over the course of 1 month and was asymptomatic at the conclusion of this course of treatment. The patient remained asymptomatic at 1-year follow-up.

Summary

While PHN has been the subject of more randomized controlled trials than any other type of neuropathic pain syndrome except diabetic neuropathy,7 no pharmacological treatment to date has shown a maximum efficacy of greater than 40%. In addition, the adverse side effects further exacerbated with advanced age demonstrate that pharmacological treatment does not resolve PHN. Laser therapy has been shown to be effective in reducing pain by 40% to 95% in patients and offers clinicians a more effective solution without adverse effects or the complications of conventional therapies.

Sources

  1. Dubinksy RM, Kabani H, El-Chami Z. Practice parameter: treatment of postherpetic neuralgia: An evidence based report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2004;63(6):959-965.
  2. Edelsburg JS, Lord C, Oster G. Systematic review and meta-analysis of efficacy, safety and tolerability data from randomized controlled trials of drugs used to treat postherpetic neuralgia. Ann Pharmacother. 2011;45(12):1483-1490.
  3. Yawn BP, Saddier P, Wollan, et al. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clinic Proc. 2007;82(11):1341-1349.
  4. Harpaz R, Prtega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008; 57(RR-5):1-30, CE2-CE4.
  5. Insinga RP, Itzler RF, Pellissier JM, Saddier P, Nikas AA. The incidence of herpes zoster in a United States administrative database. J Gen Intern Med. 2005;20(8):748-753.
  6. Gnann JW, Whitley RJ. Natural history and treatment of varicella-zoster in high-risk populations. J Hosp Infect. 1991;18(suppl A):317-329.
  7. Watson PN, Evans RJ. Postherpetic neuralgia: a review. Arch Neurol. 1986;43(8):836-840.
    Chung H, Dai T, Sharma SK, et al. The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng. 2012;40(2):516-533.
  8. Walker JB. Relief from chronic pain by low power laser irradiation. Neurosci Lett. 1983;43(2-3):339-344.
  9. Yamamoto H, Ozaki A, Iguchi N, et al. Antinociceptive effects of laser irradiation of hoku point in rats. Pain Clin. 1988;8:43-48.
  10. Lim W, Lee S, Kim I, et al. The anti-inflammatory mechanism of 635 nm light-emitting-diode irradiation compared with existing COX inhibitors. Lasers Surg Med. 2007;39(7):614-621.
  11. Moore KC, Hira N, Kumar PS, Jayakumar CS, Ohshiro T. A double blind crossover trial of low level laser therapy in the treatment of post herpetic neuralgia. Laser Ther. 1988;1:7-9.
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