Modern Research on Acupuncture Combined with Cupping in Treating Postherpetic Neuralgia

（Yinghua He） (Guanhu Yang)

Abstract: This topic is mainly based on modern clinical literature, research, analysis, and conclusion to prove the clinical application and effectiveness of acupuncture combined with cupping therapy in the treatment of herpetic zoster neuralgia. Through a computer search of China Wanfang Data Network from 2011 to 2022, statistical data of 127 clinical reports on “acupuncture combined with cupping for herpes zoster neuralgia” were obtained. After the second manual screening, 30 articles were included. Using data analysis, icon expression, and other methods to support and demonstrate. It proves that “the treatment of acupuncture combined with cupping for the prevention and treatment of herpes zoster neuralgia” has a high effective rate and high cure rate, which can shorten the course of treatment, relieve pain, and improve the quality of life of patients. This method can be used in patients with neuralgia in the acute phase of herpes zoster and can also be used in patients with postherpetic neuralgia. And because acupuncture and cupping are simple to operate, easy to master, and highly reproducible in the clinical practice of traditional Chinese medicine, this research is specially done to facilitate clinical promotion.

Keywords: Acupuncture; Cupping， Herpes zoster， Neuralgia

Herpes zoster (HZ), or shingles, is a common dermatological disease. The disease is caused by the initial infection of varicella virus (Varicella-Zoster Virus, VZV) which remains dormant in the sensory nerve ganglia in many years. and when the hosts immune function declines, the virus reactivates. The main clinical manifestations include Clustered skin vesicles and neuralgia. This type of herpes is self-limiting, usually beginning to scab over after 2 weeks, and gradually dissipating. Typically, what causes greater suffering is neuropathic pain caused by the virus invading the nerve roots. The pain manifests as spontaneous, hypersensitivity to stimuli and abnormal sensations. Postherpetic Neuralgia (PHN) is defined as nerve pain that persists for more than 1 month after the lesions have healed. 45% of PHN patients may experience anxiety, depression, and an inability to concentrate., etc. About 60% of PHN patients have suicidal thoughts. In 30% to 50% of HZ patients, the pain can last for more than one year, with some cases lasting up to 10 years or longer (Consensus on Diagnosis and Treatment of Postherpetic Neuralgia after Herpes Zoster, 2016).

The combination of acupuncture and cupping therapy has shown satisfactory therapeutic effects in the treatment of postherpetic neuralgia (PHN). This method can be applied during the acute phase as well as in chronic pain conditions of PHN patients. It can be used alone or in combination with Western medicine. By organizing and summarizing clinical evidence from practice, the aim is to provide evidence and promote the use of this approach in order to relieve and alleviate the pain of patients.

Materials and methods

According to the statistical data of the studies collected from China Wanfang Data Network between 2011 to 2022 through computer retrieval, 127 articles were obtained using “acupuncture”, “cupping”, “herpes zoster” and “neuralgia” as keywords. We included “filiform needles”, “plum-blossom needles”, “three-edged needles”, “electroacupuncture”, etc., combined with literature on cupping treatment, and excluded studies including “fire needles”, “floating needles”, “pressing needles”, “rolling needles”, “traditional Chinese herbal medicine”, “Miao medicine”, “Western medicine”, “moxibustion”, “thread moxibustion”, “Zhuang medicine”, “far infrared rays”, etc. Based on these criteria 30 studies were included in our analysis.

1.Pain Score: Visual Analog Scale (VAS) (Image source: MedSci Measuring System)

2.Efficacy evaluation: a. Cure: VAS score after treatment is 0 points; b. Significantly effective: VAS score decreased after treatment but >= 4 points; c. Effective: VAS score decreased by > = 2 points after treatment, but < 4 points; d. Ineffective: After treatment, the VAS score decreased by < 2 points or the score remained unchanged or even increased. (Van Roo JD, 2011)

3.Hamilton Depression Rating Scale (HAMD)

4.Quality of Life Assessment Form （Dermatology Life Quality Index，DLQI）

5.Pittsburgh Sleep Quality Index (PSQI)

6.Pain Relief Time: The time required for 30% pain relief、

The 30 included literatures were researched, analyzed and evaluated

Summary of the basic treatment plan: multi-point acupuncture around the local area of the herpes lesions, acupuncture on the affected meridians and related Jiaji points, acupuncture with cupping on flat areas where cups will adhere, only acupuncture on uneven areas where cups will not adhere. Use sterile needles and acupuncture tools and select glass cups or vacuum suction cups which can be thoroughly cleaned or disposed of after use. Wear disposable sterile gloves. Follow routine disinfection procedures and keep the treated area clean and dry after treatment.

Results and Evaluation

The samples of observation group and treatment group were P>0.05, there was no significant difference.

N-Sample size, d-days (unit of time), min-minutes (unit of time), PHN-postherpetic neuralgia, HAMD-Hamilton Rating Scale for Depression, VAS-Visual Analog Scale for pain rating.

1.scussion by category of different control groups: Discussion by category according to the selection of the observation group and the control group.

Apuncture combined with cupping vs. Western medicine, 10 articles: Through the following conclusions, it is demonstrated that acupuncture combined with cupping is superior to Western medicine in treating herpes zoster neuralgia. See below

Acupuncture combined with cupping vs. simple acupuncture, 5 articles: Through the following conclusions, it is demonstrated that acupuncture combined with cupping is superior to simple acupuncture in treating herpes zoster neuralgia. See below.

(Acupuncture combined with cupping + Western medicine) vs. Western medicine, 3 articles: Through the following conclusions, it is confirmed that acupuncture combined with cupping is effective in treating herpes zoster neuralgia. In clinical treatment, acupuncture combined with cupping therapy can be used in conjunction with Western medicine to relieve pain effectively and quickly for patients. See below.

(Acupuncture combined with cupping + western medicine) vs (acupuncture + western medicine), 6 articles: Through the following conclusions, it is proved that acupuncture combined with cupping and western medicine can relieve herpes zoster neuralgia better than those treatments without cupping as a control group. See below.

Clinical observation of acupuncture combined with cupping. (No control group), 6 articles: Through the following conclusions, it is shown that acupuncture combined with cupping has a significant effect on herpetic neuralgia. See below.

2.The Classification and Discussion of Different Courses of the Disease: According to acute herpetic neuralgia and chronic pain PHN, classify and discuss.

Acupuncture combined with cupping in the treatment of acute herpes zoster: Among the 30 accepted articles, 10 of them were addressing acute herpes zoster. Through the following conclusions, it is demonstrated that acupuncture combined with cupping is effective in treating acute herpes zoster, treating neuralgia, and effectively preventing the occurrence of PHN. See below.

Acupuncture combined with cupping for the treatment of PHN: Among the 30 studies adopted, 20 of them addressed chronic pain and PHN.

Through the following conclusions, it is demonstrated that acupuncture combined with cupping shows significant effectiveness in treating postherpetic neuralgia PHN. See below.

3.

Comprehensive analysis and summary: Based on the above analysis, 30 selected literatures were summarized and analyzed as follows. The results demonstrate that acupuncture combined with cupping therapy is an effective and significantly beneficial treatment for postherpetic neuralgia (PHN). Please refer to the figure below for detailed information.

Discussion

For patients with acute herpes zoster, the main purpose of treatment is to heal the skin lesions, relieve pain, and prevent the occurrence of PHN. Modern medicine offers active antiviral interventions, and the clinical use of neurotrophic agents, analgesics, and other medications, which have shown certain efficacy. The early use of antiviral drugs does have a blocking effect on the virus, but some patients still suffer from unbearable pain. Many HZ patients experience pain before the appearance of the rash, which often leads to missed optimal treatment timing and prolonged pain. Long-term and large-scale use of analgesic drugs can damage the liver and kidneys and irritate the gastrointestinal mucosa, which can cause acute and long-term issues that cannot be ignored. Although many PHN patients take neurotrophic agents for extended periods, the relief of pain-related suffering is not always significant. The development of drug tolerance due to long-term medication in PHN patients is also a factor that needs to be considered.

The encircling needling technique in traditional Chinese acupuncture originated from the “Leopard Spot Needling” and “Yang Needling” methods described in the “Ling Shu o Guan Zhen” section. The technique of needling the collaterals derives from “Collateral Needling” among the nine needling techniques mentioned in the “Ling Shu o Guan Zhen.” It states, “The defensive qi stays where it is, while the pathogenic qi is expelled by needling and the application of stones.” This refers to the theory of needling the superficial layers of the skin. Modern medical research has confirmed that bloodletting therapy can accelerate local blood circulation, aid in the resolution of local tissue inflammation and edema, alleviate nerve irritation and compression and promote nerve repair and regeneration (Bo Dongsheng, 2012; Chen Qiang, Chen Yunling, 2013). In the book “Clinical Guidelines and Medical Cases,” it is stated, “Long-standing pain can be alleviated by strengthening the righteous qi and dispelling pathogenic factors, leading to recovery. When it enters the collaterals, any lingering pathogenic factors within the qi and blood of the collaterals, whether deficiency or excess, cold or heat, can all result in pain relief.” Exogenous evils invade the body and enter through the meridians, where evil qi remains, causing the human body to feel pain. At this time, it is necessary to strengthen the body and eliminate the evil, and then cup after pricking, so that the toxic qi can be eliminated and the pain relieved.

《Medical Origins》 said, “If there are evils in the blood, they must be removed. If the blood that comes out is black, it will eventually turn red, and once it turns red one should stop the bleeding, otherwise the treatment can be harmful.” Modern research has confirmed that the negative pressure produced by cupping can induce a series of neuroendocrine responses in nerves and muscles and at the same time stimulate the metabolism of the skin lesion area to stimulate and accelerate the removal of metabolic waste and toxic factors, thereby shortening the course of the disease, effectively treating herpes zoster neuralgia, and preventing and postherpetic neuralgia. Cupping can also promote local blood circulation in skin lesions, enhance the permeability of blood vessel walls, and improve the body’s tolerance to pain, thereby effectively relieving pain. (Lu Shoukang, 2007)

In conclusion, acupuncture combined with cupping therapy can achieve significant therapeutic effects in the clinical treatment of postherpetic neuralgia (PHN)

Conclusion and Outlook

Based on literature retrieval and analysis, it can be concluded that acupuncture combined with cupping therapy provides superior efficacy in the treatment of postherpetic neuralgia (PHN) compared to acupuncture alone, as well as Western medicine’s analgesics, antiviral drugs, and neurotrophic agents. The early application of acupuncture plus cupping therapy has the highest efficacy rate, significantly reducing the duration of pain in herpes zoster, preventing, and minimizing the occurrence of postherpetic neuralgia, improving patients’quality of life, and alleviating or eliminating depression. This method can be applied not only to patients in the acute phase of herpes zoster but also to a wide range of PHN patients. And, because acupuncture and cupping are simple to apply, easy to replicate, low in cost, non-toxic, and have limited side effects in TCM clinical practice, this study aims to promote its application in clinical settings. In clinical application, it can be carried out simultaneously with Western medicine treatment or alone, and there is no contradiction or conflict with modern medicine. Clinically, it can also be expanded to treat neuralgia caused by other diseases and relieve pain for patients on a larger scale.

When performing acupuncture and cupping therapy, it is important to be mindful of the regulations and restrictions set by local acupuncture authorities. At the same time, it is hoped that laws and regulations related to traditional Chinese medicine can be established and implemented to respect clinical efficacy and relieve patients’pain. Non-vesicular herpes zoster, which is difficult to diagnose, can lead to treatment delays. Therefore, early treatment methods such as acupuncture combined with cupping are particularly valuable in providing relief for patients with this type of condition. Infrared therapy using a red-light lamp is often used in conjunction with acupuncture and cupping therapy for postherpetic neuralgia. Unfortunately, this study did not include a joint discussion on the combination of these treatments. It is hoped that future research can provide better organization and evidence for the combined use of these therapies. Floating needles, beryllium needles, and fire needles have also been gradually reported for their effectiveness in treating postherpetic neuralgia. However, due to factors such as specialization, technicality, patient acceptance, as well as regional regulations, their widespread application is limited. Therefore, they have not been included in this discussion.

Author information：

Yingwen He, Furong Chinese clinic，Arizona, USA 85716；

Guanhu Yang，holds a Bachelor’s degree in Traditional Chinese Medicine from Zhejiang Chinese Medical University, a Master’s degree from Nanjing Chinese Medical University, and a Ph.D. in Respiratory Medicine from Kanazawa Medical University in Japan. He completed his postdoctoral research in Pulmonary Biology at Cincinnati Children’s Hospital Medical Center in the United States. Currently, he serves as a Clinical Professor at Ohio University College of Medicine, a visiting professor at eleven medical colleges and universities including Beijing University of Chinese Medicine, and the Director of the International Acupuncture and Rehabilitation Research Institute at Wenzhou Medical University. Additionally, he holds the position of Vice President in several professional committees of the World Federation of Chinese Medicine Societies. In the state of Ohio, USA, he operates two traditional Chinese medicine clinics. He is a special invited reviewer for over 30 SCI journals, including Pharmacological Research, and serves as an editorial board member for Chinese Acupuncture and World Journal of Acupuncture. He is also the Associate Editor of the International Journal of Clinical Acupuncture. Associate editor, New England Journal of Traditional Chinese Medicine.

針刺結合拔罐治療帶狀皰疹神經痛的近代研究

賀英華 楊觀虎

摘要：本主題主要根據現代臨床文獻, 研究分析針刺結合拔罐療法對治療帶狀皰疹神經痛的臨床運用和有效性。透過電腦檢索的 2011年-2022年中國萬方資料網收錄的127篇以針刺結合拔罐治療帶狀皰疹神經痛的臨床報道的文獻為統計資料,經過人工二次檢索，最後納入文獻30篇。應用數據分析、圖標表達等方法做出支持與論證。證明針刺結合拔罐對帶狀皰疹神經痛的治療，有效率高、治癒率高，可縮短療程、減輕病痛、提高病患存活品質。此方法即可用於帶狀皰疹急性期的神經痛患者，也可用於帶狀皰疹後神經痛的患者。又由於針刺和拔罐在中醫臨床上操作簡單、易於掌握、可複製性強，特做此研究，以利推廣於臨床。

關鍵詞: 針刺，拔罐，帶狀疱疹，神經痛

帶狀皰疹（HZ），是臨床上較常見的皮膚病。 此病是由於許多年前，初次感染的水痘病毒（Varicella-Zoster Virus，VZV)潛伏在感覺神經節，當宿主免疫功能下降時，病毒的再度活動所致。 主要臨床表現為：皮膚簇集樣皰疹及病理性神經痛。 中醫叫蛇串瘡、纏腰火丹、蛇盤瘡、蜘蛛瘡等。 皮膚皰疹是有自限性的，通常2週開始結痂，並逐漸脫落。 帶給患者更大痛苦的，主要是病毒侵犯神經根而導致的神經病理性疼痛。 其疼痛表現為自發性痛、痛覺過敏、痛覺超敏、感覺異常等。 當皰疹癒合後，神經疼痛仍持續1個月以上的，醫學上定義為帶狀皰疹後神經痛（PHN）。 45% 的PHN患者的可表現為焦慮、 憂鬱、注意力不集中等。 60% 的PHN患者曾有自殺的想法。 30%~50%的HZ患者的疼痛可持續超過1年， 部分病程可達10年或更長。 （帶狀皰疹後神經痛診療共識編寫專家小組,2016）。

針刺結合拔罐對於帶狀皰疹神經痛的治療，在臨床中能夠收到滿意的療效。 此方法，既可應用在急性期，也可用於慢性疼痛的PHN患者。 即可單獨應用，也可於西醫聯合應用。 希望透過整理歸納臨床實務的證據，以論證和推廣此法，為病人解除和減輕病痛。

材料與方法

根據電腦檢索的 2011 年-2022年中國萬方資料網收錄的文獻為統計資料, 以「針刺」、「拔罐」、「帶狀皰疹」、「神經痛」為關鍵字，得到文獻127篇。 納入毫針、梅花針、三角針、電針等，結合拔罐治療的文獻，排除火針、浮針、撳針、滾針、中藥、苗藥、西藥、艾灸、線灸、壯醫、遠紅外線等 參與治療的文獻，排除綜述、重複文獻，最後納入文獻30篇。

臨床觀察指標及納入材料與方法

1.疼痛評分：視覺模擬評分法（VAS） （ 圖片來源：MedSci 梅斯-醫學計算）

2.療效評定：a.痊癒：治療後VAS 評分為0分; b. 顯效: 治療後VAS評分降低但> 或= 4分；c. 有效：治療後VAS 分數降低>或=2分，但< 4 分；d.無效: 治療後VAS 評分降低<2 分或評分無變化甚至增加。 (Van Roo JD, 2011)

3.漢密頓憂鬱量表（HAMD）

4.生活品質評估表（Dermatology Life Quality Index，DLQI）

5.睡眠品質指數表（PSQI）

6.疼痛緩解時間：疼痛緩解30%所需的時間。

納入的30篇文獻，進行研究、分析、評價。

基礎治療方案摘要：多點圍刺皰疹局部區域，針刺受累循行經絡及相關夾脊穴，平坦部位刺絡拔罐，不平坦區域可僅作刺絡處理。 選用無菌針灸針刺工具，選用玻璃罐或真空抽氣罐。 雙手戴醫用一次性無菌手套。 常規消毒，治療後保持患處清潔乾燥。

結果與評價

觀察組和治療組的樣本為P>0.05,無顯著差異。

N-樣本數，d-天（時間單位），min-分鐘（時間單位），PHN-帶狀皰疹後神經痛，HAMD-憂鬱狀態評分，VAS-疼痛評分。

1.不同對照組分類討論：根據觀察組和對照組的選取的不同，分類討論。

針刺結合拔罐VS西藥，10篇：透過如下歸納總結，證明針刺結合拔罐治療帶狀皰疹神經痛優於西醫組。 見下圖。

針刺結合拔罐VS單純針刺，5篇：透過如下歸納總結，證明針刺結合拔罐治療帶狀皰疹神經痛，優於單純的針刺治療。 見下圖。

（針刺結合拔罐+西藥）VS西藥，3篇： 透過如下歸納總結，證明針刺結合拔罐治療帶狀皰症神經痛，有效。 可以在臨床治療中，應用西藥的同時，行針刺結合拔罐治療，有效、快速的為患者減輕病痛。 見下圖。

（針刺結合拔罐+西藥）VS （針刺+西藥），6篇：透過如下歸納總結，證明針刺結合拔罐配合西藥的治療，可以有效的減輕帶狀皰疹神經痛，其優於不給與 拔罐的對照組。 見下圖。

針刺結合拔罐臨床觀察。 （未設對照組），6篇：透過如下歸納總結，證明針刺結合拔罐治理帶狀皰疹神經痛有顯著療效。 見下圖。

2.

不同病程分類討論：根據急性帶狀皰疹神經痛和慢性疼痛PHN，進行分類討論。

針刺結合拔罐治療帶狀皰疹急性期：所採納的30篇文獻當中，其中10篇為治療急性帶

狀皰疹。 透過如下歸納總結，證明了針刺結合拔罐治療急性帶狀皰疹，對神經痛的治療的有效性，以及有效的預防PHN發生。 見下圖。

針刺結合拔罐治療PHN：所採納的30篇文獻當中，其中20篇為治療慢性疼痛，PHN。

如下歸納總結，證明了針刺結合拔罐治療帶狀皰疹後神經痛PHN，效果顯著。 見下圖。

3.全面分析與總結：基於上述分析，彙整30篇所選文獻，進行如下全面分析。

證明針刺結合拔罐治療帶狀皰疹神經痛，有效且效果顯著。 見下圖。

討論

對於急性帶狀皰疹患者，修復皮損、減輕疼痛和預防PHN的發生，是治療的主要目的。 現代醫學積極的抗病毒幹預，營養神經藥物、止痛藥物等的臨床應用，也是有一定療效的。 早期使用抗病毒藥物，對病毒確有阻斷的作用，但仍有部分患者疼痛難耐。又有很多HZ患者，先疼痛後發疹，很容易錯過最佳的給藥時間，從而疼痛延綿不癒。 止痛藥物的長期大量服用，其對肝腎的損害和對胃腸黏膜的刺激，也是不能忽視的。許多PHN的患者，長期服用神經營養藥物，其疼痛帶來的痛苦，也沒有明顯的改善。PHN患者長期用藥導致的抗藥性，也是需要考慮的因素。

中醫針刺法中的圍刺法，源自於《靈樞·官針》五刺中的“豹文刺”及“揚刺法”。 刺絡法，源自《靈樞·官針》中九刺之“絡刺”，“衛氣之所留止, 邪氣之所客也, 針石緣而去之” 講的就是皮部的針 刺理論。 現代醫學研究證實,放血療法可使局部血液循環加速, 有利於局部組織炎症、水腫的消退,減輕對神經的刺激與壓迫,促進神經的修復與再生。（柏冬生，2012）（陳強,陳芸玲，2013 年）。《臨證指南醫案》“蓋久痛必增強扶正祛邪之功，使病癒。入於絡，絡中氣血，虛實寒熱，稍有留邪，皆解致痛”。外邪侵入人體，透過經絡入裡，則邪氣留存，使人體感覺疼痛。此時應扶正祛邪，刺絡後再拔罐，可使毒邪外出，使疼痛減輕。

《醫學源流》 說“凡血絡有邪者，必盡去之，若血射出而黑，必會變赤，見赤為止，否則病必不除而反為害。”現代研究證實, 拔罐的負 壓作用，可引起神經、肌肉等一系列的神經-內分泌反應，同時刺激皮損區域新陳代謝加快, 刺激代謝廢物與毒性因子清除,從而縮短病程，有效治療帶狀皰疹神經痛，並且預防和治療後 遺神經疼痛。 拔罐又能促進皮損局部血液循環,增強血管壁通透性,提高機體對疼痛的耐受性,從而有效緩解疼痛。 （陸壽康， 2007 年）

綜上，針刺結合拔罐在臨床上治療帶狀皰疹神經痛可以達到很好的療效。

結論及展望

透過文獻檢索和整理發現，對於帶狀皰疹神經痛的治療，中醫針刺結合拔罐的治療方案，其有效率既優於單純針刺的治療，也優於西醫止痛藥、抗病毒、營養神經的 治療。 而早期應用針刺加拔罐治療方案的有效率最高，能明顯縮短帶狀皰疹的止痛時間，預防和減少帶狀皰疹後遺神經痛的發生，改善患者的生活質量，減輕或消除患者的抑鬱狀態 。 此方法，不僅可用於急性期帶狀皰疹患者，也可廣泛應用於PHN患者。 又由於針刺和拔罐在中醫臨床上，操作簡單，易於掌握，容易複製，成本低廉，無毒副作用等特點，特做此研究，以利於推廣於臨床。 在臨床應用中，可與西醫治療同時進行，亦可單獨進行，與現代醫學並無矛盾衝突。 臨床亦可拓展至治療其他疾病引起的神經痛，較大範圍的為患者解除病痛。

刺絡拔罐時，應注意當地針灸局的法律法規之限制，也同時希望針對中醫的法律法規，本著尊重臨床療效、解除患者病痛為目的去製定和實施。無皰疹型帶狀皰疹，不易確診，所以更容易延誤治療，希望針刺結合拔罐的早期療法，可以為此類患者解除病痛。遠紅外線神燈治療帶狀皰疹神經痛，在臨床中常與針刺拔罐聯合應用，很遺憾此次未能進行聯合討論，希望今後可以做出更好更完善的整理和論證。浮針、鈹針、火針在臨床治療帶狀皰疹神經痛的療效也逐漸被報道，但由於專業性、技術性、患者的接受性等原因，以及受地域法規等限制，不具有應用的普遍性，故而沒有在此納入討論。\

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作者簡介：

賀英華，福榮中醫診所，美國亞利桑那州85716。

楊觀虎，浙江中醫藥大學中醫學士，南京中醫藥大學碩士，日本金沢醫科大學呼吸内科學博士, 美國辛辛那提兒童醫療中心呼吸生理學博士後。現爲俄亥俄大學醫學院臨床教授，北京中醫藥大學等十一所醫學院校的客座教授，温州醫科大學國際針灸康復研究所外方所長，並擔任世中聯多個專業委員會副會長。在美國俄亥俄州擁有兩個中醫診所，擔任Pharmacological Research 等多家SCI雜誌特約審稿專家，《中國針灸》和《世界針灸雜誌》編委，《International Journal of Clinical Acupuncture》副主編,新英格蘭中醫雜誌副主編。