I recently received an email from a friend of mine who I used to work with. She is a PTA with extensive training in manual and neuro treatments. Her father had shingles about 2 years ago, the visible shingles lasted for about 6 months. Since then, he has had post-shingles neuralgia (PSN) from his L groin to his L knee. He has been through all forms of treatment and has been on gabapentin since this began. None of the treatments to date, therapy or medicinal, have been successful in relieving his constant pain. Dry needling is the one treatment he has not trialed. Unfortunately, she is in one of the 6 states (NY, NJ, HI, CA, OR, and WA) that still has restrictions on who can needle. The nearest acupuncturist from their location is over 150 miles away. In rural areas, restrictions on skilled practitioners who can needle limits patient access. All of these states should be repealing this rule, as the AMA and Medicare, In January, 2020, drafted 2 specific CPT codes for DN, thus differentiating DN from acupuncture. I highly respect acupuncturists and all those in the medical field who strive to treat the source of a patient’s ailments vs. putting a band-aid over it, but this whole legal fight is detrimental to all parties involved. A topic we will save for future discussion.

Related: Click here to read more about the differences in acupuncture and DN

What is post-shingles neuralgia?

PSN occurs following recovery from visible shingles; however, the pain persists. Remember that the herpes virus, in whatever form, hangs out in our nerves. All forms of herpes I know of can lay dormant in the body for periods of time, then activate along nerves. When reactivation occurs, the sympathetics get turned way up, leading to reduced blood flow and increasing the concentration of pain-inducing chemicals.

This is the start of the snowball effect of:

• pain
• sympathetic stimulation
• muscle tightening
• vasoconstriction
• chemical imbalance
• homeostatic compromise

There are numerous acupuncture studies regarding needling for PSN, however, like just about all acupuncture and DN studies, the “level of evidence” is “poor.” The simple fact of the matter is, nobody is going to fork over $20 million for a longitudinal RCT about needling, which is about what a high quality, long-term RCT costs. The pharmaceutical companies can’t make money off needling, so it is not effective. Period. At least that’s what the “experts” say. Barf!

How to treat? Start with regulating the ANS

The goal of treatment should be to first regulate the ANS (autonomic nervous system), specifically, to calm down the sympathetics.

These are the most accessible areas to access the PANS. Then connect the needles from cephalic to caudal, or caudal to cephalic, depending on your channel polarity, with 1-5 Hz for 20-30 minutes. Remember, 1-5 Hz has consistently been shown to increase endogenous opioid and microvascular dilators into the bloodstream. Beta Endorphin and calcitonin gene-related peptides are two commonly cited opioids and vascular dilators, respectively.

It has been shown In acupuncture research and in many recent DN studies that microneurography, the gold standard for ANS testing, takes somewhere between 15-30 minutes to stop the fluctuation of the ANS once the needles are inserted. This is an absolutely key concept to understand. Allowing the body to fully process and respond while the needles are still in the body produces significantly superior results compared to not leaving the needles in place.

In conjunction with targeting the PANS, needle bilaterally down to the lamina of the corresponding spinal segments to the areas of PSN, needling around, and distal to, the areas of pain. Run as many channels of 1-5 Hz stim from the spine to the affected areas and vice versa. Also, include at least one channel from the spine to the opposite side musculature of the affected side. Since we know there is some type of crossover effect that occurs in the dorsal horn. This is similar to the mechanism by which impairments like CRPS and cervicogenic dizziness are thought to occur. Play around with connecting the stim in different patterns to see if you can alter the effects. Also try putting stim along the entire nerve path from root to termination. By regulating the nervous systems and decreasing the spatial and temporal summation of pain, along with normalizing tissue pathology, this crossover effect is eliminated and homeostasis returns.

I’m sure we will eventually be able to figure out exactly how all this works, but we are a long way from that. With what little understanding we have, it makes total physiologic sense how this could potentially occur. Either way, there is some type of awesome black magic, witchcraft type stuff that happens that resets our brain and nervous system. It regulates electrical activity blood perfusion in the brain and elsewhere. This has been proven using fMRI and other advanced imaging techniques in real-time during needling treatments. We have seen this to be true, repeatedly, in studies regarding Bell’s Palsy, cervicogenic dizziness / headache, urinary incontinence (PTNS), and more.

What I often see with these patients, as I do with autoimmune patients, is a flare-up or aggravation of symptoms for the first 1-2 treatments or so, with subsequent reduction of symptoms until they disappear. Be sure to educate your patients about this so they are not surprised or frightened if this happens. Needling should be the first line of treatment for all PSN cases. The only risk and the worst thing that can happen is that it doesn’t work. The typical benefit I see is a complete reduction of symptoms. Typically, treatment for PSN includes corticosteroids, gabapentin, and injections to block sympathetic hyperactivity. All of these medicines have significant risks associated with them compared to needling. Why not try needling first? The only potential negative side effect is muscle soreness, and the chance of success is high.

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