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Akupunktur untuk Nyeri

Dikompilasi oleh Ruben Dharmawan


Bagian Akupunktur Medik
Fakultas Kedokteran UNS
2012
Nyeri
Nyeri adalah fenomena
multidimensional yang kompleks
dengan sinyal nyeri disalurkan ke
beberapa lokasi yang berbeda di
sistem saraf.

3 (tiga) dimensi yang saling


berinteraksi :
1. Sensory-discriminative
2. Cognitive evaluative
Dimensi
Sensory-disciminative adalah kapasitas
untuk menganalisa intensitas, lokasi,
kualitas dan sifat nyeri.
Cognitive evaluative terkait dengan
fenomena antisipasi, atensi, sugesti,
pengetahuan dan pengalaman
sebelumnya.
Motivational-affective adalah respons
emosional kuatir, takut yang mengontrol
respons terhadap nyeri.
Serabut aferen
(kulit dan organ viscera)
Nyeri dihantarkan oleh 2 (dua) macam
serabut aferen :
1. Serabut A, bermyelin tipis, berdiameter
kecil, berkecepatan hantaran 5-30
meter/detik. Sensasinya tajam, terlokalisir
dan pricking.
2. Serabut C, tidak bermyelin, berdiameter
kecil, kecepatan hantaran 0,5-
meter/detik. Sensasinya nyeri, difus,
tumpul, tidak terlokalisir.
Nyeri neuromuskuler
Dapat berasal dari :
1. Komponen keras : tulang
2. Komponen lunak : otot, tendon,
fasia, kapsul persendian, ligamen,
pembuluh darah, berkas saraf
perifer.
Nyeri otot
Dapat terjadi melalui 3 (tiga)
mekanisme :
1. Kontraksi otot yang terlalu lama dan
keras
2. Otot mengalami iskemia
3. Otot terlalu teregang lama
Nyeri menurut TCM
1. Stagnasi energi, ditandai dengan
peningkatan rasa nyeri bila jaringan
ditekan.
2. Defisiensi energi, rasa nyeri
berkurang bila jaringan ditekan.
Pain Management

Acupuncture, chiropractic management and physical


therapy may be incorporated into pharmacologic
management of pain to enhance overall well being.

Palliative Care in Companion Animal Oncology

Rodney L. Page MS, DVM: Diplomate ACVIM (Internal Medicine,


Oncology)
College of Veterinary Medicine, Cornell University
Pathophysiology of Pain

What is pain?

An unpleasant sensory or emotional


experience associated with actual or potential
tissue damage, or described in terms of such
damage. Pain is always subjective.
Each individual learns the application of the word
through experiences related to injury in early life. It
is unquestionably a sensation in a part of the body,
but it is also unpleasant, and therefore also an
emotional experience.
Many people report pain in the absence of tissue
damage or any likely patophysiological cause;
usually this happens for psychological reasons.
(IASP. Pain 1979(6)249-
Based on clinical characteristics, inferences
can be made about the predominating types
of mechanisms sustaining pain. A
classification based on inferred
patophysiology broadly divides pain
syndromes into

nociceptive,
neuropathic,
psychogenic,
mixed, or
idiopathic.
Nociceptive Pain Mechanisms

Clinically, pain can be labeled "nociceptive" if it


can be inferred that the pain is related to the
degree of receptor stimulation by processes
causing tissue injury. Nociceptive pain involves
the normal activation of the nociceptive system by
noxious stimuli. Nociception consists of four
processes:
transduction,
transmission,
perception, and
modulation.
Normal somatosensory processing involves
interaction between afferent systems activated
by tissue injury and accompanying inflammation.
The primary afferent system includes
nociceptors (A-delta and C- fibers), signal
processing in the dorsal horn of the spinal cord,
ascending neural pathways, and thalamic and
other specialized brain structures.
Peripheral nociceptors are lightly myelinated or
non-myelinated ends of primary afferent
nociceptive (sensory neurons). Peripheral
nociceptors have various response
characteristics and they can be found in skin,
muscle, joints, and some visceral tissues.
The nociceptive process begins with
transduction (depolarization) at the peripheral
nociceptors in response to noxious stimuli.
Transmission is the process by which these
stimuli proceed along primary afferent
nociceptive axons to the spinal cord and then on
to higher centers.
Only when the impulses reach the brain are they
intellectually recognized as pain. This is
perception.
Nociceptive pain can be acute (short-lived,
remitting) or persistent (long-lived, chronic), and
may primarily involve injury to somatic or
visceral tissues.

Pain due to activation of somatic primary


afferents is termed somatic pain and is
typically localized and described as aching,
squeezing, stabbing, or throbbing. Arthritis and
metastatic bone pain are examples of somatic
pain.
Pain arising from stimulation of afferent
receptors in the viscera is referred to as visceral
pain. Visceral pain caused by obstruction of
hollow viscus is poorly localized (because most
viscera do not contain nociceptors) and is often
described as cramping and gnawing, with a daily
pattern of varying intensity. When organ
capsules are involved, the pain may be described
as sharp, stabbing or throbbing, descriptors
similar to those associated with somatic pain.

Nociceptive pain of any type can be referred


and some referral patterns are clinically relevant.
For example, injury to the hip joint may be
referred to the knee and bile duct blockage may
produce pain near the right shoulder blade. Pain
Nociceptive pain may involve acute or chronic
inflammation. The physiology of inflammation is
complex. In addition to an immune component,
retrograde release of substances from C
polymodal nociceptors also may be involved. This
neurogenic inflammation involves the
release of the endogenous pain facilitory
chemical known as substance P, as well as
serotonin, histamine, acetylcholine, and
bradykinin. These substances activate and
sensitize other nociceptors.

Prostaglandins produced at the site of injury


act to further enhance the nociceptive response
to inflammation by lowering the threshold to
noxious stimulation. Chronic inflammation with
Spinal pathways : local interconnections. Of
great importance are connections mediating so-
called "gating".

The basic idea here is that "painful stimuli"


coming into the cord on C fibres can be modified
by other inputs, which "close the gate on the
incoming pain". These inputs come from:
A delta fibres;
A beta fibres;
others.
Acupuncture causes low-frequency high
amplitude stimulation of small A delta fibres
(amongst other fibres), and this causes
inhibition of pain through gating mechanisms.

The effect of acupuncture can be blocked by


giving opioid antagonists.
Unpleasant stimuli entering via the C fibres
can be suppressed by concurrent stimulation
of A delta fibres (high amplitude low
frequency stimulation, for example by
acupuncture) or by impulses passing through
A beta fibres.
The incoming noxious pain activity flowing
through the dorsal horn is reduced by
inhibitory interneurones, presynaptic and
postsynaptic inhibition, and specific receptors
controlling ionic flux through nerve membrane
channels.

Modulatory input to these arrives via two


lateral pathways from myelinated sensory Ad
and A fibres, and via three descending
pathways from the midbrain.
A fibres arise in low-threshold
mechanoreceptors (activated by touch, brush,
tickle and conventional transcutaneous electrical
nerve stimulation [TENS]) and

Ad fibres in high-threshold
mechanoreceptors (responsive to stronger
stimulation such as acupuncture needles).
Two pathways descend in the dorsolateral
funiculus, the third is associated with diffuse
noxious inhibitory control, which is a powerful
pain-suppressing system triggered by painful
stimulation anywhere in the body.

-Endorphin is the most important pain


inhibitory neurotransmitter in the supraspinal
centres and is present in fibres connecting the
hypothalamus to the periaqueductal grey.

Interconnections between the prefrontal cortex,


limbic system (hypothalamus, hippocampus,
amygdala, cingulate gyrus) and reticular
formation are responsible for the cognitive and
emotional influences on the behavioural response
to pain.
Heterosegmental analgesia

Pain originating in one part of the body can be


reduced by strong counter-irritation in
another area. The noxious counter-irritant
(localised to one body segment) excites a loop,
via the Ad fibres, midbrain and descending
tracts, to all segments other than that of the
noxious stimulus.

Many techniques, such as cupping, cautery, skin


irritants, painful massage or joint manipulation,
resemble acupuncture and TENS with respect to
this powerful generalised effect.
Shen

Titik Lokal
Titik Ahse Qi
Titik Usu
Titik Yuan
Akupunktur Titik Luo Qi Qi
Titik Xi
Organ
Titik Shu Meridian
Titik Mu Cang Fu
Titik
Dominan
Titik Induk
Qi

Qi
Jaringan

Akupunktur Klasik
From:
www.intl.elsevierhealth.com/e-
books/pdf/131.pdf
THEORY AND BASIC SCIENCE
p.69-83
CORTEX
CORTEX

THALAMUS

HYPOTHALAMUS
HYPOTHALAMUS
PITUITARY
PITUITARY ANALGESIA
ENDORFIN BLOOD
ENDORFIN HOMEOSTASIS :
-CSF
BLOOD
-CSF IMMUNE SYST
PAG ACTH
ACTH etc
etc C.V. SYST
PAG RESP SYST
TISSUE HEALING

NRM-NRPG
SKIN
NEEDLE
HISTAMIN R
SEROTONIN
DLT HORMONES
HISTAMIN
KININ
SEROTONIN HORMONES
LIMFOKIN
KININ
DNIC
LEUKOTRIN
LIMFOKIN AFFERENTS
PROSTAGLA ENK SE NE MODIFY PAIN
LEUKOTRIN CORTI
CORTI
NDIN
PROSTAGLA DYN SENSATION
SOL
SOL
NDIN
IMMUNE
REACTION
ALT
ORGAN
ORGAN AUTONOMIC
MOTOR
GAMMA LOOP
BLOOD
BLOOD
MOTOR SPINAL CORD
MUSCLE
MUSCLE
HEADACHE
Headache is a term used to describe aching
or pain that occurs in one or more areas of
the head, face, mouth, or neck.
Headache can be chronic, recurrent, or
occasional. The pain can be mild or severe
enough to disrupt daily activities.
Headache involves the network of nerve
fibers in the tissues, muscles, and blood
vessels located in the head and at the base of
the skull.
Primary headache accounts for about 90% of all
headaches. There are three types of primary
headache : tension headache, cluster headache,
and migraine.

Tension headache is the most common type of primary


headache. Episodes usually begin in middle age and are
often associated with the stresses, anxiety, and
depression that can develop during these years.

Cluster headaches occur daily over a period of weeks,


sometimes months. They may disappear and then recur
during the same season in the following year.
Secondary headache is associated with an
underlying condition such as cerebrovascular
disease, head trauma, infection, tumor, and
metabolic disorder (e.g., diabetes, thyroid
disease).
Head pain also can result from syndromes
involving the eyes, ears, neck, teeth, or sinuses.
In these cases, the underlying condition must be
diagnosed and treated.
Also, certain types of medication produce
headache as a side effect.
Some researchers believe that a low level of
endorphins may cause frequent, severe, or
chronic headache pain. Endorphins are
painkilling compounds found in the brain.

Acupuncture is a very useful treatment. It can


balance underlying hormonal deficiencies,
tonify the gastrointestinal system, and
calm reactive blood vessels. It can support
the balancing required in any healing process.

(Healthcommunities.com, Inc.)
Pemilihan Titik :
- Titik nyeri lokal
- Fengchi (GB 20)
- Hegu (LI 4)
Migraine headaches - Are less common than
tension headaches. They are more common in
women than in men and can be debilitating.
Migraines are episodic disabling headaches that
may recur over years. Migraine sufferers often
become nauseous and are sensitive to light and loud
sounds during an episode. Some people can tell
when they are about to have a migraine headache
because they experience certain symptoms, called
an aura, before the headache occurs. These
symptoms can include visual disturbances such as
seeing spots or stripes and blurred vision.
Pemilihan Titik :
- Titik nyeri lokal
- Hegu (LI 4)
- Neiguan (PC 6)
- Zulinqi (GB 41)
- Taichong (LR 3)
TERIMAKASIH
Kompilasi berasal dari karya :
Dr. Dharma K. Widya, Mkes., SpAk.
DR. Dr. Syarif Sudirman, SpAn (K)
DR. Dr. Koosnadi Saputra, SpR (K)
Untuk kepentingan akademis.