By Robert Hayden, dC, Phd, FICC
Mac first presented for care in August 2012 with a chief com- plaint of lumbar pain, radiating down the left lateral leg to the ankle. It was worse with weight- bearing, described as approximately 5/10 in intensity, without numbness or tingling. His pain was made worse with long periods of sitting (more than 30 minutes), and ameliorated some by walking, more by lying down. He worked in a place that sold auto parts, so lifting, bending, twisting, and walking on concrete floors for long hours were part of his daily expectation.
He is a 67-year-old Caucasian male who lives with his wife of 35 years. He had a pleasant disposition and appeared in no acute distress at the time of his first exam. He denied vices (smoking, alcohol abuse, recreational drug history). At 5’11” tall and 238 pounds, he was moderately heavy.
His medical history was significant for hypothyroidism for the past 15 years, treated by Synthroid. He also took Hydrodiuril with a potassium supplement for mild hypertension with adequate control. He took Centrum Silver and glucosamine daily. His only trauma was an arm fracture in childhood. Surgical history included a hernia repair in February 2012.
On exam, there was a positive Beckterew’s and straight leg raiser test with Braggard’s on the left side, radiating pain to the left L5 dermatome. Valsalva maneuver exacerbated the back pain, particularly in a seated position. Range of motion was unremarkable except slight antalgia to the left side.
Lumbar X-ray (AP & lateral) revealed five normal lumbars, leaning to the right, with a high right Ilium that tilted the pelvis to the left. Disc spaces were well preserved. Lumbar lordosis was reduced in a manner consistent with myospasm. No soft tissue anomalies were observed. It was concluded that he likely had an L4 disc bulge, posterolateral on the left.
His lumbar pain was treated with flexion distraction success- fully over the next four weeks. He did well for several months.
Mac returned for care in early June with similar symptoms: lumbar pain at 4/10 with sciatic radiation to the left, this time more in the groin and left thigh than in the leg, although the left lateral leg also was involved. We began treatment with spinal decompression (using a Chattanooga digital traction table) in the first week of June.
On 16 June, Mac said that sometime during the previous week, he believed that the traction belt around his waist may have been too tight. He stated that it had produced a rash that felt like a rope burn, radiating from his low back to his left groin. Inspection revealed a raised rash extending from midline of the spine near L4/ L5 to the patient’s left, wrap- ping laterally and inferiorly, then anteriorly and inferiorly into the groin. Upon questioning, Mac said he believed that the rash had raised white pustules when it first arose about four days earlier. He experienced itching and burning at the site of the rash and had treated it with calamine lotion, although he noted very little success in controlling the discomfort. He had no fever or other constitutional disturbances.
Although the lesions roughly followed the path of the traction belt as applied when the patient is on a decompression table, there were no analogous lesions on the right side of the spine or groin.
The Virus: Almost every adult
in America over the age of 40 has had chickenpox, even if they do not remember it. Once inside the body, this virus (varicella) waits patiently for an opportunity to manifest itself. Specifically, it is waiting for some weakness in the immune system or a slight bio- chemical environmental change that allows this virus to run ram- pant. About one in three people in America will have this disease in their lifetime, with about 1 million infected at any given time. The risk of an outbreak increases with age and concomitant decline of immunity, with about half of the cases in people over 60 years of age. Although it is usually mostly a painful interruption of health, a recent study implicates this virus in about 100 deaths per year among people whose compromised immunity leaves them open to attack.
Because this viral infection attacks spinal nerves, the manifestation will roughly follow dermatomes unilaterally. About 20 percent of patients will have overlapping dermatomes affected. Initially there is frequently burning, itching or tingling, followed by a painful rash that scabs over within seven days. In Mac’s case, the scabbing progressed rapidly, possibly because of his vigorous use of calamine lotion, and possibly because the rash occurred in a high friction area when wearing jeans.
Although shingles cannot be transmitted from person to person, contact with someone in the early stage of the rash (before the scabbing) can transmit the virus that causes chickenpox in someone who has not already had it. Thus, it is prudent to keep the rash covered and use normal handwashing precautions. In our case, we cleaned our table and its accessories with 70 percent isopropanol, allowing it to dry overnight.
The worst-case scenario is the development of post-herpetic neuralgia (PHN), an extended version of shingles pain that may last for months or years. Treatment is more difficult with such progression.
Treatment: First, the implications of this condition were explained to the patient. An informed decision needed to be made. We could refer him to a primary care physician, but med- ical treatment has very limited effectiveness with this condition. We could treat conservatively with a modality that is potentially far more effective and safer than medical treatment, then refer if not successful within one week. After weighing these options, the patient opted for the latter.
Medical treatment for shingles varies with the approach of the practitioner. Most will use antiviral drugs, such as acyclovir, to initially slow the progression of the virus. Topi- cal antibiotics may be used to prevent secondary bacterial infection of the blisters. Topical anesthetics like benzocaine might be used to control the pain of the rash. Oral pain medication may include over-the-counter acetaminophen, ibuprofen or narcotics. Antidepressants are sometimes used to augment pain medication. Gabapentin, an anti-seizure drug, may be used to capitalize on its side effect of raising pain threshold. Steroids are sometimes administered. All of these, sadly, may be ineffective in addressing the condition or the sometimes horrendous pain it can produce.
Can chiropractic help with an active shingles case? I know of no evidence that chiropractic can help with this condition, but the chiropractor can.
There is a growing body of anecdotal evidence describing the positive effect of infrared laser on this condition. I can personally attest to the success of the application of laser with shingles, as we have now treated several with positive results.
Low level laser therapy (LLLT) has been used in Asia and Europe for about 40 years. It was approved by the Food and Drug Administration (FDA) in 2002 for the reduction of pain and inflammation in musculoskeletal conditions. It is proposed by some that neural tissue may be photosensitive in such a way that LLLT may reduce pain sensitivity by interrupting fast pain fibers. LLLT is also believed to speed healing by accelerating protein synthesis and mitochondrial energy production.
Mac was treated with a dual probe/4 diode infrared laser with a 635 nm wavelength. The laser was focused on his lesions for 30 – 45 minute sessions, one on the back and one on the groin on Monday, Tuesday, and Thursday of the week following his breakout. During this time, spinal decompression was dis- continued to avoid any abrasion of the rash. He continued to use the calamine lotion at home. He wore loose fitting clothes to stay comfortable.
On Thursday, following the third treatment, dramatic im- provement was noted in his rash. He reported that by Wednesday, his burning pain was gone, leaving some mild sensitivity where the skin was damaged. He denied any further paresthesia or pain along the site of the rash.