#Trigeminal verse

[secret-engima]

Someone please come up with a Time Travel Fix it, preferably for FFXV, with the title of Trigeminal. It means "three twins." Am I thinking of three KG coming back? Yes. Am I thinking Lib, Crowe, and Nyx? Maybe, that would be fun. Might make more sense for it be three of the KG that made it to the Dawn though. In other news, fun times with anatomy homework!

Ohhhh.

oooooOOOOOOHHHH This.

This is a good idea.

*picks up Plunny* yes. Yes pls.

Gonna go with three KG that made it to the Dawn because those guys have saved my tail a BUNCH and they need more love. (in this, Iphigenia is an OC who represents the Glaive you play in Comrades btw)

For the record, Luca is the dark skinned, brown haired NPC in the suit and Tabul is the dark skinned, black haired NPC wearing the Galahdian coat and with a cornrow ponytail. They are actual NPCs in the Comrades game and I like them.

...

Luca, Tabul, and Iphigenia do not expect to time-travel. Who does? They do not know why they were picked, or how it happened. All they know is that one moment they are staring at the rising sun, crying at finally, finally being out of the darkness, the next they are waking up, startled and afraid, in their respective beds well in the past. They panic, they stare out at sunlight they haven’t seen in ten years, at a thriving world that they know is in ruins. They wonder if this is a dream, or insanity, or if the Accursed has caught them in an illusion like he was rumored to be capable of.

They are not sure what to make of it. Their younger bodies, the sunlight, their relatives that are alive and well.

Luca and Tabul find each other within the week, they both live in Little Galahd, and they are both desperate to find another who Remembers. They put their heads together, and by week two decide ... it’s not a dream. This is REAL somehow.

Considering they were there when the six Astrals came down to judge them all for the crimes of a few of their number ... time-travel actually doesn’t seem totally impossible.

But they wonder who they are missing. If anyone else Remembers. But discreet poking around Little Galahd reveals no one, not that they can see anyway. They debate and plan and finally they decide to join the Kingsglaive again. If they are going to change anything, they need magic to do it.

And it’s a few weeks into basic training that they find their third member.

It’s easy to spot her, casually towering over the heads of most of the glaives at her looming six foot four inches of pure muscle, her face clear of the network of scars they had grown used to seeing over the last ten years (scars from the Betrayal, a ship crash she had barely survived). She’s a new recruit, signed up as soon as she stepped off the truck she’d hitchhiked to Insomnia on, her skin dark now only because of its nature, not from layers of dirt that never came off. Brown eyes spot them staring at her across the way and Luca whistles, short and shrill in a signal the Glaives had come up with to compensate for the lack of light with which to read hand signs in the field.

Iphigenia, for that is the only name they know her by, her old one abandoned after the Betrayal, smiles slightly and calmly saunters over to them. No one gets in her way, all the other recruits and even full glaives scatter to clear a path. Luca and Tabul aren’t surprised.

It would seem Iphigenia had not chosen to change her style in the slightest. Not even here in the past, years before the Betrayal was anything but a bad dream and not a terrible reality.

That would require forgiving herself as much as forgiving others, and they both know that isn’t going to happen anytime soon. If ever.

Iphigenia lowers herself to sit next to them, one hand absently flicking a few stray strands of newly dyed soft pink hair out of her face. As recruits, they can’t customize their uniforms yet, but they are allowed a few personal items, and the purple ribbon holding back most of her cherry blossom stands out.

Just like the slightly red, definitely new tattoo on her left arm, starting from her wrist and curling up to her bicep stands out. The vibrant green snake with its tongue of thorns, surrounded by pink roses, is as screamingly loud a message to their Galahdian senses as ever.

Pink, purple, green. Betrayal, Loyalty, Watchfulness.

It could mean several things. That she has been Betrayed by one to whom she was Loyal and will not be taken off guard again. That she Betrayed someone to whom she owed Loyalty and others should watch out lest she do the same. It could even mean she considers herself so Betrayed she will never give Loyalty again.

But there is a conspicuous lack of braid in her hair, as there has been for years, and while Luca can see some of the glaives already wondering if the tall, silent new recruit is a Mainlander who doesn’t know the color code, Luca knows the truth.

She is Galahdian. One who chose to sheer off her braid at the base and throw it at the Six’s feet. And the message behind her colors is not one but all three.

Iphigenia had never forgiven herself for falling for the traitorous talk. Sonitus, Tredd, Axis, and Luche had been fellow Glaives, people to whom she had been Loyal (particularly her cousin, her blood clan who she had trusted the judgement of above all others, and the mere thought made Tabul’s blood burn in rage for her), and they had betrayed her by tricking her into treason. But she had also chosen to follow them into treason, which meant she was the one who had Betrayed the man who held her Loyalty (the king, King Regis, father of the Chosen King who was to save them all).

The last is in the tattoo. She has given her Loyalty once, she has been Betrayed and Betrayed another once. She gave the last of her Loyalty to the Chosen King that day the Draconian drew his blades and bid the glaives to defend themselves and prove their right to live, when he declared that they would only be absolved should the Chosen King grant forgiveness. She will not give it to anyone else ever again. Not even Clan.

“Never could do subtle, could you,” Tabul sighs as he sees the way the crowd watches them, watches Iphigenia. Iphigenia just smiles crookedly and shrugs, never one for spoken word, not since a bad encounter with a Psychomancer ripped out her tongue (an injury that no longer exists, but seven years of habit is hard to undo).

“So what’s the plan?” she signs in the hybrid mix of GSL KSL, and the much trickier NSL Biggs and Wedge had taught them, the one they’d studied as a joke more than anything until it became useful for coded communication.

Tabul and Iphigenia look to Luca, their strategist, and the dark-skinned woman sips her water in thoughtful silence. She sets the water down with a clink and then smiles as she signs back, “Step one, get our magic back.”

“And step two?” Tabul signs.

“I’ll let you know when we’ve hit step one.” Luca signs at the same moment Iphigenia casually flicks out-

“Stab Drautos in his-” she ends the phrase with a gesture that is not traditionally sign language but is universally understood as something sensitive and insulting. Tabul chokes on his drink, having not expected a reason to laugh so soon in the day. Luca just sighs.

“I wonder if Lord Scientia had this much trouble wrangling his idiots,” she mutters in sign, the barest waggle of her fingers to form the letters almost like she’s trying to whisper with her hands.

Iphigenia just huffs in amusement and goes back to watching the other non-time-traveling glaives try to figure out whether Iphigenia is a screaming warning sign or just an oblivious Mainlander.

[a-long-walk-in-the-forest]

Genjutsu

• Definition

Hypnosis and illusionism to confuse the mind…

It’s some kind of hypnotic technique that drags the target’s mind to an illusory world and may cause confusion or physical/mental exhaustion. The main difference from other jutsu is that it does not directly affect the user’s body. There are many types of Genjutsu that may be used to attack or give a handicap to those who use them.

Advantages: It’s hard to detect who used it. Not only that, there can be many targets all at once.

Disadvantages: Prolonged use exhausts the user and it hardly deals physical damage to the target.

Source: first databook

• Doesn’t just cause illusions but can also be used to control people to some extent (we can probably guess the extent of this control by what the cranial nerves can do)

• Cranial nerves

1. The olfactory nerve transmits sensory information to your brain regarding smells that you encounter. Nerve signals are sent to areas of your brain concerned with memory and recognition of smells.

2. The optic nerve is the sensory nerve that involves vision. The information received by your rods (black and white vision and night vision) and cones (colour vision) is transmitted from your retina to your optic nerve. 

3. The oculomotor nerve has two different motor functions: muscle function and pupil response.

 Muscle function. Your oculomotor nerve provides motor function to four of the six muscles around your eyes. These muscles help your eyes move and focus on objects.

 Pupil response. It also helps to control the size of your pupil as it responds to light.

4. The trochlear nerve controls your superior oblique muscle. This is the muscle that’s responsible for downward, outward, and inward eye movements.

5. The trigeminal nerve is the largest of your cranial nerves and has both sensory and motor functions.The trigeminal nerve has three divisions, which are:

 Ophthalmic. The ophthalmic division sends sensory information from the upper part of your face, including your forehead, scalp, and upper eyelids.

 Maxillary. This division communicates sensory information from the middle part of your face, including your cheeks, upper lip, and nasal cavity.

 Mandibular. The mandibular division has both a sensory and a motor function. It sends sensory information from your ears, lower lip, and chin. It also controls the movement of muscles within your jaw and ear.

6. The abducens nerve controls another muscle that’s associated with eye movement, called the lateral rectus muscle. This muscle is involved in outward eye movement.

7. The facial nerve provides both sensory and motor functions, including:

 moving muscles used for facial expressions as well as some muscles in your jaw

 providing a sense of taste for most of your tongue

 supplying glands in your head or neck area, such as salivary glands and tear-producing glands

 communicating sensations from the outer parts of your ear

8. Your vestibulocochlear nerve has sensory functions involving hearing and balance. It consists of two parts, the cochlear portion and vestibular portion:

 Cochlear portion. Specialized cells within your ear detect vibrations from sound based off of the sound’s loudness and pitch. This generates nerve impulses that are transmitted to the cochlear nerve.

 Vestibular portion. Another set of special cells in this portion can track both linear and rotational movements of your head. This information is transmitted to the vestibular nerve and used to adjust your balance and equilibrium.

9. The glossopharyngeal nerve has both motor and sensory functions, including:

sending sensory information from your sinuses, the back of your throat, parts of your inner ear, and the back part of your tongue

 providing a sense of taste for the back part of your tongue

 stimulating voluntary movement of a muscle in the back of your throat called the stylopharyngeus

10. The vagus nerve is a very diverse nerve. It has both sensory and motor functions, including:

communicating sensation information from your ear canal and parts of your throat

sending sensory information from organs in your chest and trunk, such as your heart and intestines

allowing motor control of muscles in your throat

stimulating the muscles of organs in your chest and trunk, including those that move food through your digestive tract (peristalsis)

providing a sense of taste near the root of your tongue

11. Your accessory nerve is a motor nerve that controls the muscles in your neck. These muscles allow you to rotate, flex, and extend your neck and shoulders.

12. Your hypoglossal nerve is the 12th cranial nerve which is responsible for the movement of most of the muscles in your tongue.

•Taught during latter years in the academy

Stuff they learn in all years: taijutsu, ninjutsu

Stuff they learn in early years: senjutsu

Stuff they learn in later years: genjutsu

• Getting rid of it

Chakra disturbance (can be done by the person under the illusion or someone else). 

Chakra disturbances can be caused through any of the senses, sight, hearing, smell, taste or touch. It can also be done using physical pain.

• Examples

First databook:

1. Mist Servant Technique (Kasumi Juusha no Jutsu)

•Genjutsu, D-rank, Supplementary The tenebrous phantoms arise from the fog and multiply endlessly!! The somber, uncanny shinobi phantoms appear out of trees and rocks one after the other, cornering the enemy. They all move sluggishly, but each time one of them receives a blow it multiplies, making the fog-dwelling ghost part quite the real article. There’s definitely no escape from those black shinobi phantoms…

2. Temple of Nirvana Technique (Nehan Shouja no Jutsu)

• Genjutsu, A-rank, Supplementary, Close to long range Fluttering in the air, the white feathers lure people into a realm of torpor!! A Genjutsu that generates a fluttering rain of sleep-inducing, illusory white feathers. Whoever sees them as they fall, piling up and covering the whole target area will experience Eden-like bliss and fall into a state of tranquil slumber. No matter how much one resists the hypnotic spell the desire to sleep is instinctive, and there’s no fighting it!!

3. Demonic Illusion: False Surroundings Technique (Magen: Kokoni Arazu no Jutsu)

• Genjutsu, C-rank, Supplementary, All ranges A thin layer of deception covering all that the eye can see!! A Genjutsu that allows one to trick others into mistaking the place they’re in for another. This technique’s main feature is that it can be cast over an extensive surface, therefore any and all who step into the illusion’s area of effect will fall under the spell. That said, it might not work so well on people who are well-versed or otherwise skilled in Genjutsu.

4. Demonic Illusion: Hell Viewing Technique (Magen: Narakumi no Jutsu)

• Genjutsu, D-rank, Supplementary, Close range This jutsu reveals the fears that dwell inside people’s hearts!! Whether they are aware of it or not themselves doesn’t matter: pictured in the bottom of their hearts, everyone has an image of the one thing they least want to ever see. This Genjutsu is a technique that draws forth such an image from within the heart and has one mistake it for reality. In other words, if the mental image is a gruesome one, the shock will be accordingly great.

Second databook:

1. Bringer-of-Darkness Technique (Kokuangyou no Jutsu)

• Genjutsu, A-rank, Supplementary, Mid to long range Everything falls into a tenebrous hellhole! Inside the cruel obscurity, there is no room for countermeasures!! A Genjutsu which exerts an hallucinatory effect upon the eyesight, stealing all light away. A world of darkness, as if a thick, jet-black curtain had been dropped. No matter how skilled someone is, they have no option besides turning into sitting ducks…

2. Tsukuyomi

• Genjutsu, Kekkei Genkai, Supplementary, Close range An inner hell as eternal as Heaven and Earth. The grip held onto the principles of all creation thoroughly annihilates one’s heart and soul!! Amidst the insight and hypnosis possessed by Sharingan, is a supreme Genjutsu, born from the aforementioned hypnosis: Tsukuyomi. Originally, people on the face of the Earth live bound by limitations like time, gravity, and space; and how people exert their abilities within those restrictions is what separates the victors from the vanquished. But in the mental world where the caster drags their opponent, the Tsukuyomi jutsu gives them control over those very limitations! Namely, this means inside the Genjutsu, the physical world’s common sense is completely irrelevant and opposing the caster is impossible. Somebody caught into the Tsukuyomi find themselves into a strange world of infinity, their fate entirely lying inside the caster’s hands. Some time, they will undergo the torments of Hell, and some other time, they will be repeatedly shown a horrendous, hellish picture of agony and mayhem, with no idea of when either of those will end. As a result, the poor prisoner can only wait until the collapse of their psyches…!! Even a body made of iron or the speed of light are powerless before this jutsu, which is the reason why it is feared as the most powerful.

3. Demonic Illusion: Mirror Heaven and Earth Change (Magen: Kyou Tenchi-ten)

• Genjutsu, Kekkei Genkai, Supplementary, Close range The mechanics of a false image is duplicated by these eyes, its effects largely turned back onto the enemy!! One decrypts a Genjutsu that has been applied onto them, and casts back a jutsu with identical effects onto the opponent!! It’s a form of illusion reversal, but in order to instantly read through a jutsu and cast it in return, the Sharingan’s power is necessary. As Genjutsu is initially used to confuse the enemy, this technique which sends it right back to its caster deals a high amount of mental damage, more than anything else. Every half-baked Genjutsu will fall prey to the mirror that is Sharingan!!

4. Demonic Illusion: Tree Binding Death (Magen: Jubaku Satsu)

• Genjutsu, B-rank, Supplementary, Close range Ensnared and captured. Such is the nefarious influence of the dire tree!! One of the Genjutsu that have been passed along since ancient times in Konoha. One is completely robbed of their mobility as they see the mirage of a tree coiling itself around them! Given that the subject remains conscious, this jutsu proves extremely efficient for information-gathering.

5. Demonic Flute: illusionary warriors’ manipulation melody

• Genjutsu, B-rank, Supplementary The melody of death that controls three demons Tayuya’s ninjutsu that controls three demons that have been summoned with the sound of the flute. Tune varies according to behavior pattern of demons and gets complex to avoid getting analyzed.

6. Demonic Flute: Phantom Sound Chains (Mateki: Mugen Onsa)

• Genjutsu, B-rank, Supplementary, All ranges The sound of the flute beckons hellish captivity. Restraining the limbs and taking all freedom away!! One of the Genjutsu that rely on the sound of the flute. Whoever hears it will be assailed by the vivid sensation that their limbs have been fastened with sturdy ropes, thus becoming unable to move about freely. At the same time, they are fed morbid hallucinations, which makes it also possible to run them down mentally. Given that the means of transmission is sound-based, it has a large range of effectiveness, on top of which it can be applied even without knowledge of the enemy’s position, which makes for an exceedingly convenient jutsu.

7. Bringer-of-Darkness Technique (Kokuangyou no Jutsu)

• Genjutsu, A-rank, Supplementary, Mid to long range Everything falls into a tenebrous hellhole! Inside the cruel obscurity, there is no room for countermeasures!! A Genjutsu which exerts an hallucinatory effect upon the eyesight, stealing all light away. A world of darkness, as if a thick, jet-black curtain had been dropped. No matter how skilled someone is, they have no option besides turning into sitting ducks…

Third databook: Won’t include because I cannot be bothered to type it out.

Fourth databook:

1. Izanagi

• Genjutsu, Kekkei Genkai, Defensive, Close to mid range The forbidden Doujutsu that connects illusion and reality! During battles where defeat was not an option, this great eye power made its name, the power that was used by the Uchiha Clan for a long time. It is activated by making the [hand] seals of the Rabbit, Boar, and Ram while the user has the Sharingan active. From there, the jutsu erases any harmful reality to the user for a brief moment and then replaces it with a reality in favour of the user, helping the user to solve complicated situations. The duration that the jutsu is active depends on the user’s power capacity. It is a dangerous Doujutsu that leaves the user practically invincible. By using it, the user risks blindness. He hides even death within an illusion, for the duration of the jutsu.

2. Izanami

• Genjutsu, Kekkei Genkai, Supplementary, Close range The forbidden Doujutsu that creates an infinite cycle that decides the destiny!! A scene of an opponent’s action is recorded by the user’s Doujutsu, then an identical scene needs to be recreated. The opponent is then trapped infinitely in a loop between the first and second scenes that were recorded. To escape this Genjutsu, the victim must accept his original destiny. Reforming the conduct allows someone to escape Genjutsu.

3. Kotoamatsukami

• Genjutsu, Kekkei Genkai, Supplementary, All ranges The eye dominates the consciousness, transforming the one who sees into a pawn. The Mangekyou Sharingan of Uchiha Shisui uses the strongest Genjutsu. The user exerts influence on the opponent, manipulating his actions without his being aware of it. Victory can be achieved without a battle, a wonderful jutsu. The constraints of Impure World Reincarnation were rewritten by their power. The Sharingan that Danzou stole from Shisui was used to manipulate Mifune in order to secretly dominate the conference of the Five Kage.

4. Infinite Tsukuyomi (Mugen Tsukuyomi)

• Genjutsu, Kekkei Moura, Supplementary, All ranges The divine eye observes all things of creation, caught in this prison of infinite dreams!! On a full moon night, the Rinne-Sharingan, capable of manipulating the world, is reflected on the moon, and then its light illuminates people on earth, placing them in eternal Genjutsu… The light emitted by this technique can cross obstacles, so even if a person is hiding in a closed place, he cannot escape! Those who have fallen into infinite dreams are enveloped by the roots of the God Tree, which have been expanded on a global scale by God: Nativity of a World of Tress, and have their chakra sucked into eternity. The circular eye floating on the moon!! The moon turns into a Rinne-Sharingan, putting all of humanity into a Genjutsu! Rinnegan’s appearance appears in the eyes of those affected by jutsu. Those involved in jutsu are trapped by trees and their chakra is absorbed.

[doctorfortmj]

A Comprehensive Guide to TMJ Syndrome Treatment Options

The temporomandibular joint which is also known as TMJ connects your lower jaw(mandible) to your skull. TMJ disorder happens due to the displacement of the temporomandibular joint present where your skull and jawbone meet. Sometimes the problems go away with self-care tips but if the symptoms persist then you need to visit a reputed clinic that can offer you a variety of TMJ syndrome treatments to help you relieve the pain.

Let's check out some effective TMJ syndrome treatments that may help relieve the pain associated with TMJ disorder.

Diagnosis- A TMJ specialist or doctor will listen carefully to your symptoms and examine your jaw. The doctor will observe the opening and closing of the jaw, and press on areas of the jaws to identify the root cause of pain and discomfort. On the basis of the diagnosis, the doctor will recommend dental X-rays, CT scans or other tests before proceeding to treatment.

Acupuncture- It is considered century-old medicine which is completely safe and effective for several TMJ symptoms such as bruxism, sleep disorders or neck pain.. It helps with muscle relaxation by releasing endorphins and serotonin. The process also regulated the release of hormones that causes a stress response.

Botox treatment- Botox is an effective treatment for jaw and head pain. Botox injections are injected into the temporalis muscle which limits muscle function, thereby reducing pain and discomfort. 

Mouth Guards-  These are specially designed to help alter the functions of the jaw muscles causing the TMJ disorder. They hold the jaw in the correct position, reducing tooth grinding and clenching. It is one of the effective treatments for TMJ disorder.

Where can you find a clinic that offers TMJ syndrome Treatments?

Connecticut & NY TMJ is a reputed dental clinic in the heart of New York that offers the above-mentioned TMJ syndrome treatments and other disorders such as burning mouth syndromes, bruxism, migraines and trigeminal neuralgia. They have expert TMJ specialists who are well-versed in different treatment procedures to help you get out of the discomfort.

If you are experiencing any TMJ symptoms then stop waiting and click on this link to book your appointment.

[backpaintreatmentinindia]

Postherpetic Neuralgia – Time heals… We are here if it fails…

What causes Postherpetic Neuralgia (PHN)?

Herpes Zoster infection (Shingles) is caused by the reactivation of the virus which causes chickenpox. If one has had chickenpox before, the virus that causes it remains inside the body in an inactive state till it gets an opportunity to spread once again. The reactivation may happen as one ages or as a result of reduced immunity. The virus spreads along a nerve producing the typical rash of Herpes Zoster in the area supplied by the nerve. Rash generally heals in 2-4 weeks and is accompanied by pain, numbness, itching and altered sensitivity in the area.

One out of five patients with Herpes Zoster may still have persisting pain after 120 days (90 days as per WHO) of rash onset and this condition is referred to as Postherpetic Neuralgia (PHN). In PHN the nerve cells can get damaged leading to increased excitability and persisting pain. Approximately 50% of patients recover within a year and the course is variable in the remaining. In one study it was observed that the proportion of patients with spontaneous resolution of pain decreased with increasing time since the onset of herpes zoster.

Who are at risk for developing persisting pain/Postherpetic Neuralgia after the Herpes Zoster (Shingles) infection?

The risk factors can be viewed as those relating to the

Risk of developing Herpes Zoster infection– such as increasing age and low immunity. Low immunity may be secondary to diseases such as cancer or medications used to suppress immunity such as those used in organ transplant, treatment of inflammatory arthritis and chemotherapy.

Risk of persisting / non resolving pain– Pain preceding the onset of rash, severe pain at the time of rash onset, widespread rash and older age have been associated as risk factors for persisting pain (PHN).

Early use of antiviral agents (within 72 hours of rash onset) & corticosteroids (if indicated), early aggressive pain control may offer some protection, reducing the risk of developing PHN after Herpes Zoster infection.

What are the symptoms of Postherpetic Neuralgia?

PHN generally presents as burning, shooting, throbbing or electric shock like pain occurring spontaneously or in response to stimuli such as touch. Commonly involved areas include the chest wall (thoracic dermatomes) and around the eye (ophthalmic branch of the trigeminal nerve). Pain may be more severe at night time and during periods of stress. The affected area may

Be hypersensitive with daily activities such as taking bath, wearing clothes becoming difficult as the touch of clothes or water is painful. This is known as allodynia where non painful stimuli become painful.

Feel itchy

Feel weak (muscle weakness)

Develop skin pigmentation and scarring in the area of rash

How is Postherpetic Neuralgia diagnosed?

PHN is rare in the age group below 50 years and incidence increases after the age of 60 years. Generally the diagnosis can be made clinically as most patients would give the history of Herpes Zoster Infection/ typical painful rash in the affected area. In many cases the persisting skin colour changes and scarring also aid the diagnosis. The rash generally involves only one side and does not cross the midline.

Which medications can help to reduce the pain in Postherpetic Neuralgia?

Different types of medication are used to control pain in PHN and these include:

Neuropathic Agents

PHN pain does not respond well to the usual painkiller and special types of painkillers known as the neuropathic painkillers may be required. This includes medications such as

Anticonvulsants

Antidepressants

These are well known painkillers commonly used for nerve pain. The choice of drugs best suited for an individual is made after a thorough assessment and taking into account a number of factors such as age of patient, pain severity, other medical problems, general health etc. The dose of the selected medications is increased gradually giving the body a chance to adapt and reducing the side effects. These medications may take a few weeks to produce their full effects and hence it is important that you stick to the schedule recommended by your pain physician. Often a combination of different agents is utilised to maximise your gains and to keep the individual drug doses low so that the side effects are minimised. These medications not only help with the pain but can also help in improving sleep, mood, and quality of life.

Opioids

This class includes morphine like drugs which are often used for severe pain, in combination with the above mentioned medications. Opioids can be classified as weak opioids (like tramadol) and strong opioids (fentanyl patches, morphine, oxycodone etc). Some of these are available in long acting and short acting formulations. These drugs are best prescribed by a specialist who is well versed with the available options and the limitations /advantages of each of them. It is important that you adhere to the schedule as prescribed by your pain specialist. Whilst deciding on medications the side effects should be kept in mind and discussed with the patients. Sometimes the side effects are used as an advantage like sedation with night time medications to improve sleep.

Topical agents

These have the advantage of fewer side effects and are sometimes used preferentially in the elderly/ frail patients and when side effects of oral medications limit their usage. They include various types of gels, creams and patches. Some contain local anaesthetic and soothing agents. Local anaesthetic patches may be especially useful in cases of increased sensitivity to stimuli such as touch. Unfortunately some of the topical options such as 8% capsaicin patch are not available in India as yet.  A one off 60 minute application of Capsaicin 8% patch can provide significant pain reduction for a few months.

What other treatment options are available for pain control in Postherpetic Neuralgia?

A number of options are available to control PHN pain apart from the medications and these include:

Drug infusions- These are commonly used in cases with severe pain, especially when the other measures have not been successful. They work by reducing the sensitivity of the nerves transmitting the pain signals. These infusions are generally administered in day care setting which means that you do not have to stay in the hospital overnight. These are low risk options with the potential of significantly reducing the pain for weeks/ months. They can help reduce the requirement of other regular strong medications thereby reducing the side effects.

Nerve blocks, Dorsal Root Ganglion Block and Epidural injections can be considered based on the pain severity and the site involved. These procedures involve injection of local anaesthetic and steroids to reduce the pain and sensitivity of the nerves. They are generally performed as a day case using x-ray or ultrasound guidance with no requirement for overnight hospital stay. In severe acute cases however hospital stay may be required if continuous epidural drugs are administered to control the pain.

Sympathetic nerve blocks including stellate ganglion block are used for severe uncontrolled pain. Initially a diagnostic block is performed to assess if these special nerves (called the sympathetic nerves) are involved in transmitting the pain signals to the brain. These nerves do not carry pain signals normally but can get involved in chronic pain conditions. If the response to the diagnostic block is positive then other ways of prolonging the effect can be considered. Depending on the duration of the effect, these blocks and hence they may need to be repeated.

Pulsed radiofrequency lesioning (PRF) is a safe, non-destructive modality that can help in reducing the PHN pain. This treatment is performed as a day case, using special equipment and requires  x-ray or ultrasound guidance. The treatment  involves modulating the way pain signals are transmitted and processed and the resulting pain relief can last for weeks/ months.

Neuromodulation including Peripheral Nerve Stimulation, Peripheral Nerve Field Stimulation ― Peripheral Nerve Stimulation (PNS) in a non invasive treatment that is performed by placing the stimulating electrode in close proximity to the involved peripheral nerve. The nerve can be easily located using ultrasound in most cases, with the stimulation performed transcutaneously. More invasive methods may involve placing electrodes through the skin or in the spine (Spinal cord Stimulators). In Peripheral Nerve Field Stimulation (PNFS), stimulating electrodes are placed below the skin (percutaneously) close to the painful area and are removed once the treatment has been performed.

Tags- Back Pain Treatment in India Cervical Pain Treatment in India Knee Pain Treatment in India

[back-pain-treatment-in-delhi]

Postherpetic Neuralgia – Time heals… We are here if it fails…

What causes Postherpetic Neuralgia (PHN)?

Herpes Zoster infection (Shingles) is caused by the reactivation of the virus which causes chickenpox. If one has had chickenpox before, the virus that causes it remains inside the body in an inactive state till it gets an opportunity to spread once again. The reactivation may happen as one ages or as a result of reduced immunity. The virus spreads along a nerve producing the typical rash of Herpes Zoster in the area supplied by the nerve. Rash generally heals in 2-4 weeks and is accompanied by pain, numbness, itching and altered sensitivity in the area.One out of five patients with Herpes Zoster may still have persisting pain after 120 days (90 days as per WHO) of rash onset and this condition is referred to as Postherpetic Neuralgia. In PHN the nerve cells can get damaged leading to increased excitability and persisting pain. Approximately 50% of patients recover within a year and the course is variable in the remaining. In one study it was observed that the proportion of patients with spontaneous resolution of pain decreased with increasing time since the onset of herpes zoster.

Who are at risk for developing persisting pain/Postherpetic Neuralgia after the Herpes Zoster (Shingles) infection?

The risk factors can be viewed as those relating to the

Risk of developing Herpes Zoster infection– such as increasing age and low immunity. Low immunity may be secondary to diseases such as cancer or medications used to suppress immunity such as those used in organ transplant, treatment of inflammatory arthritis and chemotherapy.

Risk of persisting / non resolving pain– Pain preceding the onset of rash, severe pain at the time of rash onset, widespread rash and older age have been associated as risk factors for persisting pain (PHN).

Early use of antiviral agents (within 72 hours of rash onset) & corticosteroids (if indicated), early aggressive pain control may offer some protection, reducing the risk of developing PHN after Herpes Zoster infection.

What are the symptoms of Postherpetic Neuralgia?

PHN generally presents as burning, shooting, throbbing or electric shock like pain occurring spontaneously or in response to stimuli such as touch. Commonly involved areas include the chest wall (thoracic dermatomes) and around the eye (ophthalmic branch of the trigeminal nerve). Pain may be more severe at night time and during periods of stress. The affected area may

Be hypersensitive with daily activities such as taking bath, wearing clothes becoming difficult as the touch of clothes or water is painful. This is known as allodynia where non painful stimuli become painful.

Feel itchy

Feel weak (muscle weakness)

Develop skin pigmentation and scarring in the area of rash

How is Postherpetic Neuralgia diagnosed?

PHN is rare in the age group below 50 years and incidence increases after the age of 60 years. Generally the diagnosis can be made clinically as most patients would give the history of Herpes Zoster Infection/ typical painful rash in the affected area. In many cases the persisting skin colour changes and scarring also aid the diagnosis. The rash generally involves only one side and does not cross the midline.

Which medications can help to reduce the pain in Postherpetic Neuralgia?

Different types of medication are used to control pain in PHN and these include:Neuropathic AgentsPHN pain does not respond well to the usual painkiller and special types of painkillers known as the neuropathic painkillers may be required. This includes medications such as

Anticonvulsants

Antidepressants

These are well known painkillers commonly used for nerve pain. The choice of drugs best suited for an individual is made after a thorough assessment and taking into account a number of factors such as age of patient, pain severity, other medical problems, general health etc. The dose of the selected medications is increased gradually giving the body a chance to adapt and reducing the side effects. These medications may take a few weeks to produce their full effects and hence it is important that you stick to the schedule recommended by your pain physician. Often a combination of different agents is utilised to maximise your gains and to keep the individual drug doses low so that the side effects are minimised. These medications not only help with the pain but can also help in improving sleep, mood, and quality of life.OpioidsThis class includes morphine like drugs which are often used for severe pain, in combination with the above mentioned medications. Opioids can be classified as weak opioids (like tramadol) and strong opioids (fentanyl patches, morphine, oxycodone etc). Some of these are available in long acting and short acting formulations. These drugs are best prescribed by a specialist who is well versed with the available options and the limitations /advantages of each of them. It is important that you adhere to the schedule as prescribed by your pain specialist. Whilst deciding on medications the side effects should be kept in mind and discussed with the patients. Sometimes the side effects are used as an advantage like sedation with night time medications to improve sleep. Topical agentsThese have the advantage of fewer side effects and are sometimes used preferentially in the elderly/ frail patients and when side effects of oral medications limit their usage. They include various types of gels, creams and patches. Some contain local anaesthetic and soothing agents. Local anaesthetic patches may be especially useful in cases of increased sensitivity to stimuli such as touch. Unfortunately some of the topical options such as 8% capsaicin patch are not available in India as yet.  A one off 60 minute application of Capsaicin 8% patch can provide significant pain reduction for a few months.

What other treatment options are available for pain control in Postherpetic Neuralgia?

A number of options are available to control PHN pain apart from the medications and these include: Drug infusions- These are commonly used in cases with severe pain, especially when the other measures have not been successful. They work by reducing the sensitivity of the nerves transmitting the pain signals. These infusions are generally administered in day care setting which means that you do not have to stay in the hospital overnight. These are low risk options with the potential of significantly reducing the pain for weeks/ months. They can help reduce the requirement of other regular strong medications thereby reducing the side effects. Nerve blocks, Dorsal Root Ganglion Block and Epidural injections can be considered based on the pain severity and the site involved. These procedures involve injection of local anaesthetic and steroids to reduce the pain and sensitivity of the nerves. They are generally performed as a day case using x-ray or ultrasound guidance with no requirement for overnight hospital stay. In severe acute cases however hospital stay may be required if continuous epidural drugs are administered to control the pain.Sympathetic nerve blocks including stellate ganglion block are used for severe uncontrolled pain. Initially a diagnostic block is performed to assess if these special nerves (called the sympathetic nerves) are involved in transmitting the pain signals to the brain. These nerves do not carry pain signals normally but can get involved in chronic pain conditions. If the response to the diagnostic block is positive then other ways of prolonging the effect can be considered. Depending on the duration of the effect, these blocks and hence they may need to be repeated. Pulsed radiofrequency lesioning (PRF) is a safe, non-destructive modality that can help in reducing the PHN pain. This treatment is performed as a day case, using special equipment and requires  x-ray or ultrasound guidance. The treatment  involves modulating the way pain signals are transmitted and processed and the resulting pain relief can last for weeks/ months. Neuromodulation including Peripheral Nerve Stimulation, Peripheral Nerve Field Stimulation ― Peripheral Nerve Stimulation (PNS) in a non invasive treatment that is performed by placing the stimulating electrode in close proximity to the involved peripheral nerve. The nerve can be easily located using ultrasound in most cases, with the stimulation performed transcutaneously. More invasive methods may involve placing electrodes through the skin or in the spine (Spinal cord Stimulators). In Peripheral Nerve Field Stimulation (PNFS), stimulating electrodes are placed below the skin (percutaneously) close to the painful area and are removed once the treatment has been performed.

Tags >> Post Herpes Zoster Pain Treatment, Post Herpetic Neuralgia, Postherpetic Neuralgia

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Edward P. Trimmier, DMD, MEd, is a Remarkable Dentist with His Own Private Practice in Spartanburg, South Carolina

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Edward P. Trimmier, DMD, MEd, obtained his doctorate of dental medicine in 1994 from Boston University - The Henry M. Goldman School of Dental Medicine in Boston, Massachusetts, followed by a certificate in hospital dentistry with a focus on oral surgery and pathology at Catholic Medical Center in Manchester, New Hampshire, and Long Island Jewish Medical Center in Queens, New York (1996) and a certificate in anesthesiology at Brookdale University Hospital and Medical Center in Brooklyn, New York (1999). Dr. Trimmier also holds a certificate in differential diagnosis and treatment of head ache types, TMJ, trigeminal neuralgia, and head and neck anatomy from the University of California, Los Angeles (2001). In 2004, he obtained a certificate in dental implants from the Medical College of Georgia in Augusta, Georgia, and in 2015, he completed rotational training in anesthesiology, emergency room medicine, internal medicine, oncology, physical diagnosis, oral surgery, and prosthodontics at The Washington DC VA Medical Center/ George Washington University Hospital. Prior to his dental degree, Dr. Trimmier earned a Bachelor of Science degree in Psychology and a Bachelor of Arts degree in Religion and Neuroscience at Wofford College in Spartanburg, South Carolina (1977) and a Master of Education degree in Leadership and Administration at Converse College in Spartanburg, South Carolina (1989). For more information about Edward P. Trimmier, DMD, MEd, please visit https://www.findatopdoc.com/doctor/8136780-Edward-Trimmier-dentist-South-Carolina.