APPLICATION OF ONNURI SU JOK ACUPUNCTURE IN THORACIC POSTHERPETIC NEURALGIA

V.V. Malakhovski, M.D., Chair of non-pharmacological methods of treatment and clinical physiology, Moscow I.M.Sechenov Medical Academy

Herpes zoster is a severe disease caused by varicella-zoster virus. Disease frequency depends on age and immune status and varies from 0.4 to 1.6 cases per 1000 for persons under 20 years old, and 4.5 to 11 cases per 1000 in the age group after 80. Most often herpes zoster affects thoracic dermatomas: 50 to 55% of all occurrences. The second place in involvement frequency is occupied by the first ramus of trigeminal nerve [1, 11].

Affliction begins as separate pustules followed by a group of blisters which stay from 7 to 10 days but may also persist for a month, often resulting in scarring, anaesthesia, changed pigmentation and pain in the affected area.

Pain is a characteristic sign of herpes zoster. It may start several days before eruption, sometimes being the only manifestation of the disease. For the most part, patients complain of burning, crushing, and lancinating pain. Senestopathic component is often present. Pain is accompanied by considerable emotional colouring. A characteristic example of this is provided by the English equivalent expression for herpes zoster - "belt of roses from Hell" [10]. Also, one can point to hypersthesia, dysesthetic disorders, itching, and such a phenomenon as allodynia - painful response to non-painful stimuli. In the majority of patients, these pathological symptoms disappear within a month after a herpes zoster attack.

If the described symptoms persist for a longer period, after disappearance of vesicles, such cases are regarded as manifestations of postherpetic neuralgia (PHN). The risk of postherpetic neuralgia increases with age. So, 47% of persons after 60, and 73% after 70 have postherpetic neuralgia following herpes zoster attacks. Similarly, pains are more difficult to control in older patients. Duration of illness for more than one year was reported in 22% of patients over 55 and 48% of patients over 70 years old, respectively [11]. Pains cause sleep disorder, lower mood and efficiency thus contributing to PHN impact on life quality in both short-term and long-term perspectives. Even duly started antiviral medication (aciclovir, zovirax, valtrex, etc.) does not prevent PHN development in many elderly patients.

Existing therapeutic techniques aimed at controlling the pain syndrome, which is the leading one in PHN clinical picture, normally prove to be of low effectiveness which stimulates specialists to look for new treatment methods. It should be noted that the basic PHN treatment method is psychopharmacotherapy with predominant use of antidepressants (amitriptyline, etc.) and anticonvulsants (carbamazepine, etc.) [1, 9, 11] have considerable side effects. Recently, non-pharmacological approaches to PHN treatment have found wider application, acupuncture being one of them [1, 3, 12].

We examined and treated 110 patients with thoracic postherpetic neuralgia whose age varied from 50 to 80 (average 65+15). Disease lasted from 1 month to 5 years. Most often, D4-D7 dermatomas were afflicted. Importantly, postherpetic neuralgia affects predominantly one side of the body, so we think it necessary to point out that right thoracic dermatomas were involved in 45% of cases, left ones in 55%. The described group did not include persons who suffered from diseases of blood, lymphoproliferative and other oncologic diseases (contraindications for acupuncture), nor patients with severe somatic and endocrine pathology, and thase after 80.

Treatment effectiveness was assessed by a modified pain test (MPT) [scales: 1 - pain frequency, 2 - pain duration, 3 - pain severity, 4 - sensory perception of pain, 5 - emotional-affective evaluation of pain, 6 - product scale (6 points - maximum manifestation, 0 - no pain)] [4] (These scales served as a basis for the diagrams presented in the article).

Onnuri Su Jok acupunture was administered by different methods for eighty patients (20 men and 60 women). Thirty patients (15 men and 15 women) formed a comparison group. It included those patients who received amitriptyline treatment 50 to 75 mg daily, for 6 to 8 weeks. The results of treatment by amitriptyline are shown in Diagram 1.

Diagram 1. Composite effectiveness of amitriptyline medication in patients with thoratic PHN (30 persons)

Treatment by Onnuri Su Jok acupuncture methods was conducted in three stages. At the first stage, all patients underwent treatment by correspondence systems [5]. At the second (for patients who did not show high results after treatment by correspondence systems) - Six Ki method was applied, using correspondence systems [6, 7]. At the third (for patients in whom Six Ki method was not highly effective) - by palm lines (using correspondence systems) [8].

Treatment was carried out in both the standard correspondence systems of the hand and additional systems, and also in the minisystem. Influence was exerted: on the spinal column projection points (at the level of affected segments), in the skin manifestations projection area by the standard system and minisystem (Fig. 1), and in the posterior central gyrus projection area (on both the thumbs). If radiating pains were present, radiation projection areas were employed. In case of low effectiveness for as long as two sessions, similar actions were undertaken on feet. A session lasted from 20 to 40 minutes depending on the nature of pain, patient's age, duration of the disease, and also on the dynamics of pain severity during each session. Thus, with dominating shooting pain, short duration of disease, and decrease of pain severity within 15 to 20 minutes after the beginning of the session, the procedure duration was less. When complaints referred to more burning, crushing pains, itching and longer duration of disease, and no progress in algesic manifestations, the procedure lasted 40 minutes.

Fig. 1. Treatment of Herpes zoster by correspondence systems (massage, acupuncture)

The number of sessions varied from 8 to 10 on an alternate day basis or once in three days. Maximal results were obtained in 35 patients with duration of disease up to six months (Diagram 2).

Diagram 2. Dynamics of pain syndrome in the group with high effectiveness of correspondence systems therapy (35 patients)

Another 45 patients, treatment by correspondence systems alone proving insufficient (Diagram 3), underwent 6 Ki therapy. To assess energy imbalance in thoracic PHN, the following aspects were taken into account (in terms of Oriental medicine):

Diagram 3. Dynamics of pain syndrome in the group with low effectiveness of correspondence systems therapy (45 patients)

1. Herpes zoster is a viral disease - manifestation of the energies of Coldness and, partially, Wind;

2. Disease is more expressed in elderly persons - Coldness energy property;

3. Disease often accompanied overcold - Coldness;

4. Pain increases with lower temperatures - manifestation of Coldness energy;

5. Disease is provoked by draught - Wind energy;

6. Peripheral nerves of thoracic spine - Hotness;

7. Chest integument - Hotness.

These are indications of incoming excessive Coldness and Wind energies in the Hotness energy system. Treatment was conducted on the basis of this conclusion. In patients, branch Hotness was tonified on the spinal cord byol-meridian or on the Governor byol-meridian followed by sedation of branch Coldness or Wind energies on the same byol-meridians depending on the provocative agent (overcold or draught) (Fig. 2). However, the said approaches are applicable only to PHN up to eight weeks long. In cases of more prolonged disease the main criterion for choosing the right prescription will be the nature of pain. Thus, if acute pains of neuralgic character dominated, Dryness was sedated on the spinal cord byol-meridian (Fig. 3). For dull persistent pains, sedation of Humidity energy was alleviating (Fig. 4). Burning sensations and senestopathic manifestations could be controlled by sedation of branch Hotness on the Governor byol-meridian (Fig. 5). The seeming contradiction of tonification and sedation of branch Hotness energy in PHN results from application of these approaches at different stages of a pathological process. Duration of a session was 30 to 50 minutes and depended on the dynamics of severity of pain syndrome.

Fig. 2. Treatment of cold-induced Herpes zoster: (tonification of branch Hotness in AH-Hotness)	Fig. 3. Treatment of acute pain symptom in Herpes zoster (sedation of branch Dryness in AH-Hotness)

Fig. 4. Treatment of constant dull pain in Herpes zoster (sedation of branch Hymidity in AH-Hotness)	Fig. 5. Treatment of senestopathic manifestations and burning sensations in Herpes zoster on the byol-meridian of the Governor

Positive results were obtained in 25 patients (Diagram 4). In 20 cases, when the disease lasted for more than 30 months, Six Ki treatment had little effect (Diagram 5).

Diagram 4. Dynamics of pain syndrome in the group with high effectiveness of Six Ki therapy (25 patients)	Diagram 5. Dynamics of pain syndrome in the group with low effectiveness of Six Ki therapy (20 patients)

These patients proceeded to the third therapeutic stage, treatment by palm lines. Dryness, Humidity and Hotness energies were sedated on the line of Hotness, depending on the nature of pains (see above). In ten patients treatment was effective enough (Diagram 6). Ten sufferers turned out to be therapy-resistant (Diagram 7).

Diagram 6. Dynamics of pain syndrome in the group with high effectiveness of palm lines therapy (10 patients)	Diagram 7. Dynamics of pain syndrome in the group with low effectiveness of palm lines therapy (10 patients)

Employment of the proposed techniques had a considerable therapeutic effect in 87% cases of thoracic PHN (p<0.05). Total efficiency of Onnuri Su Jok acupuncture in postherpetic neuralgia is presented in Diagram 8.

Diagram 8. Composite effectiveness of Su Jok acupuncture methods in patients with thoratic PHN (80 persons)

It is noteworthy, that treatment by correspondence systems was more effective in females, while the Six Ki method and palm lines therapy did not show significant sex-based variations. With some exceptions, therapy was becoming less effective as the patients' age increased.

Absence of effect of Onnuri Su Jok methods in some patients is apparently due to irreversible anatomic and physiological alterations in the affected area, exhausted reserves of the organism. Importantly, this group was noted for considerable duration of the disease (3 to 5 years) and marked depressive anxiety or asthenic depression that could be diagnosed before PHN developed (according to past history). This group of patients further received therapy of amitriptyline (75 to 100 mg daily) in combination with carbamazepine (400 to 600 mg daily) for as long as eight and more weeks in order to obtain therapeutic effect comparable with other groups of patients.

Onnuri medicine method is aimed at restoring impaired homeostasis [2], activation of reparative processes in the organism on the informational, energy, functional, cellular and biochemical levels.

Treatment by correspondence systems is applicable in lighter PHN cases, shorter period of illness, since this kind of treatment has a compensatory and function-regulating influence. Treatment by Six Ki is more effective with severe and prolonged PHN, which can be explained by more profound influence on the processes going on the energy-and-information level. Positive results of palm lines treatment in most hard cases of PHN are probably due to maximal individualization of approach as compared with standard location of energy points in Six Ki method. Therefore, combined application of different Onnuri Su Jok acupuncture methods allows to obtain considerable effectiveness in treatment of thoracic postherpetic neuralgia.

To summarize, we can recommend treating patients with shorter duration of disease by correspondence systems. For longer terms, Six Ki method and palm lines therapy combined with correspondence points is advisable.

Application of Onnuri Su Jok therapy is efficient in thoracic PHN, saving patients many side effects from antidepressant and anticonvulsant medication. In cases of co-morbid affective disorders, anxiety and asthenic depression, or if PHN persists for years, Onnuri Su Jok therapy should be combined with psychopharmacotherapy.

References

1. Grachev, Yu.V., Kukushkin, M.L. et al. Clinic and treatment of herpetic trigeminal ganglioneuropathy.- Journal of neuropathol. and psych. 1998, No.11, p.4-8.
2. Zilov V.G., Kudaeva L.M., Paltseva I.S. "Su Jok acupuncture methods in view of theory of functional systems of organism".- In: Materials of I International congress "Traditional medicine and food: theoretical and practical aspects", 1994, p.37-38.
3. Malakhovski V.V. "Complex therapy of pain syndrome in postherpetic neuralgia".- In: Theses of Russian scientific conference "Pathological pain", Novosibirsk, 1999, p.178-179.
4. Modified pain test (handbook for medical practitioners), NII TML, Moscow, 1996.
5. Park Jae Woo. Guide to Su Jok therapy, Seoul, 1993.
6. Park Jae Woo. Lectures on Su Jok therapy. I, Moscow, 1994.
7. Park Jae Woo. Lectures on Su Jok therapy. II, Moscow, 1998.
8. Park Jae Woo. Treatment by palm lines.- In: Onnuri Medicine, 1999, No.3, p.50-55.
9. Yakhno N.N. Application of anticonvulsants for treating chronic neurogenic pain syndromes.- in: Anticonvulsants in psychiatric and neurologic practice, Saint Petersburg, 1994, p.317-325.
10. Gilden D.H. Herpes zoster with postherpetic neuralgia - persisting pain and frustration. N Engl J Med, 1994, v. 330 (13), pp. 932-934.
11. Kost R.G., Straus S.E. Drug therapy: postherpetic neuralgia - pathogenesis, treatment and prevention. N Engl J Med, 1996, v. 335 (1), pp. 32-42.
12. Liu Zhiwen Chen Jing. Analysis on 85 cases of herpes zoster treated with acupuncture.- In: Academic Conference of the Tenth Anniversary of WIAS, Beijing, 1997, p. 201.
13. Watson C.P., Chipman M., Reed K., et al. Amitriptyline versus maprotiline in postherpetic neuralgia: a randomized, double-blind, crossover trial. Pain, 1992, v. 48 (1), pp. 29-36.