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
3. Motivational-affectieve
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 Aδ, 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)249-252, ex Shipton, 1993)
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 nonmyelinated 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 is also distinguished by its location.
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 nociceptive stimulation may be the source
of persistent pain.
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 Aß fibres, and via three
descending pathways from the midbrain.
Aß 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.
ß-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
Akupunktur
Titik Lokal
Titik Ahse
Titik Usu
Titik Yuan
Titik Luo
Titik Xi
Titik Shu
Titik Mu
Titik
Dominan
Titik Induk
Qi
Qi
Qi
Meridian
Organ
Cang Fu
Qi
Qi
Jaringan
Akupunktur Klasik
From: www.intl.elsevierhealth.com/ebooks/pdf/131.pdf
THEORY AND BASIC SCIENCE p.69-83
CORTEX
THALAMUS
HYPOTHALAMUS
PITUITARY
ANALGESIA
ENDORFIN
PAG
BLOODCSF
IMMUNE SYST
C.V. SYST
RESP SYST
TISSUE HEALING
ACTH etc
NRM-NRPG
NEEDLE
SKIN
HISTAMIN
SEROTONIN
KININ
LIMFOKIN
LEUKOTRIN
PROSTAGLANDI
N
R
DLT
HORMONES
DNIC
AFFERENTS
ENK
DYN
SE NE
CORTI
SOL
ALT
ORGAN
GAMMA LOOP
MUSCLE
AUTONOMIC
MOTOR
BLOOD
MOTOR
SPINAL CORD
HOMEOSTASIS :
MODIFY PAIN
SENSATION
IMMUNE
REACTION
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.