AKUPUNKTUR PADA BERBAGAI

KASUS NYERI
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 pathophysiological 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
pathophysiology 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.
The ultimate perception of pain depends on both activity in
this afferent system and its modulation at multiple levels of
the nervous system.
Pain modulation is determined by by activity in the
endorphinergic system and other pain modulating systems. In
the endorphinergic system, analgesia is mediated by the
binding of endogenous opioid compounds to special subsets
of receptors: mu, delta, and kappa. Endorphins are widely
distributed and closely associated with systems known to
regulate homeostasis, response to stress, and pain.
In this very complex system, other neurotransmitters, such as
serotonin and norepinephrine also play a role in the
endogenous pain modulating system.
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. There are several.
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.
This arrangement has several practical consequences:

Transcutaneous Electrical Nerve Stimulation (TENS) works

Dorsal column stimulation (DCS) works
Acupuncture works!
Rubbing the skin locally helps decrease pain!
TENS works by high-frequency, low amplitude stimulation of
larger peripheral fibres, and this inhibits transmission of pain
through the "gates".

DCS is similar, but works by antidromically stimulating the

same A beta fibres.
Acupuncture works in a different way: it causes low-
frequency high amplitude stimulation of small A delta fibres
(amongst other fibres), and this also causes inhibition of pain
through gating mechanisms.

Another difference between acupuncture and TENS is that

the effect of acupuncture can be blocked by giving opioid
antagonists, which don't inhibit the effect of TENS.
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.

Examples of the latter include TENS (transcutaneous

electrical nerve stimulation) and the simple expedient of
rubbing the skin, which is well known by mothers to
decrease perception of pain !
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.
Acupuncture points are supplied by high concentrations of
nerve endings and bundles, mast cells (used for immune
function) lymphatics and capillaries.
In addition, acupuncture points have a lower electrical
resistance, compared with surrounding skin.
Dry skin has a direct current (DC) resistance of about 200,000
to 2 million ohms.
Resistance decreases to about 50,000 ohms at acupuncture
points.
Acupuncture points can be accurately located with
acupuncture point-finders that measure ohms to determine
point location.
Acupuncture channels show up as a different color than
surrounding tissue on photographs taken with infrared
imaging.
 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

THALAMUS

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

NRM-NRPG
SKIN
NEEDLE
HISTAMIN R
SEROTONIN
DLT HORMONES
KININ
LIMFOKIN DNIC
LEUKOTRIN AFFERENTS
PROSTAGLANDI ENK SE NE MODIFY PAIN
CORTI
N DYN SENSATION
SOL
IMMUNE
REACTION
ALT
ORGAN
AUTONOMIC
MOTOR
GAMMA LOOP
BLOOD
MOTOR SPINAL CORD
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.
• Tension headaches - Are the most common type of headache. They are
often accompanied by tension in the muscles of the head, neck, and
shoulders. The pain from tension headaches is a constant, dull pain and is
often described as a band squeezing around the head, like a tight hat. The
pain is not incapacitating and usually occurs on both sides of the head.
Tension headaches come on gradually and can last from hours to days.

• Cluster headaches - Are less common than other kinds of headaches and
occur more often in men than in women. Cluster headaches come on
suddenly with severe pain centered around one eye, which becomes
watery. Nasal congestion may occur on the same side of the face. These
headaches usually last about 45 minutes and can occur several times a
day. Cluster headaches typically occur over a period of weeks or months,
known as a cluster period, and then disappear for weeks or months until
the next cluster occurs.
• 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.
• 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
• A migraine is a common type of headache that may occur
with symptoms such as nausea, vomiting, or sensitivity to
light. In many people, a throbbing pain is felt only on one side
of the head.

• Some people who get migraines have warning symptoms,

called an aura, before the actual headache begins. An aura is a
group of symptoms, usually vision disturbances, that serve as
a warning sign that a bad headache is coming. Most people,
however, do not have such warning signs.
Pemilihan Titik :
• - Titik nyeri lokal
• - Hegu (LI 4)
• - Neiguan (PC 6)
• - Zulinqi (GB 41)
• - Taichong (LR 3)
TRIGEMINAL NEURALGIA
• A chronic and severe electric-shocking and burning pain at
one side of the face
• Attacks are initiated by tactile irritations in a trigger area of
the trigeminal nerve
Pemilihan Titik :
• Titik nyeri lokal
• Xiaguan (ST 7)
• Yifeng (TE 17)
• Hegu (LI 4)
• Waiguan (TE 5)
• Zusanli (ST 36)
TOOTHACHE
• Toothache or tooth pain is caused when the nerve root of a
tooth is irritated. Dental (tooth) infection, decay, injury, or loss
of a tooth are the most common causes of dental pain.

• Pain may also occur after an extraction (tooth is pulled out).

Pain sometimes originates from other areas and radiates to
the jaw, thus appearing to be tooth pain.

• The most common areas include the jaw joint

(temporomandibular joint or TMJ), ear pain, and even
occasional heart problems.
Pemilihan Titik :
• Xiaguan (ST 7)
• Hegu (LI 4)
• Neiting (ST 44)
NECK PAIN
• Mostly caused by cervical spondylopathy, intervertebral
disc hernia, vertebra injury, and dislocation, as well as
whiplash or soft tissue injury

• Acupuncture has exceptional results in treating neck pain

Pemilihan Titik :
• Jiaji terkait
• Tianzhu (BL 10)
• Fengchi (GB 20)
• Jianjing (GB 21)

Catatan :
• Dapat dikombinasi dengan elektroakupunktur
atau pemanasan
FROZEN SHOULDER
• Frozen shoulder, or adhesive capsulitis, is a condition that
causes restriction of motion in the shoulder joint.

• The cause of a frozen shoulder is not well understood, but

it often occurs for no known reason.

• Frozen shoulder causes the capsule surrounding the

shoulder joint to contract and form scar tissue.
• Most often, frozen shoulder occurs with no associated injury
or discernible cause. There are patients who develop a frozen
shoulder after a traumatic injury to the shoulder, but this is
not the usual cause.

• Frozen shoulder most commonly affects patients between the

ages of 40 to 60 years old, and it is twice as common in
women than in men
Pemilihan Titik :
• Titik nyeri lokal
• Huatojiaji
• Waiguan (TE 5) kedua sisi
• Tiaokou (ST 38)
TENNIS ELBOW
• Tennis elbow (lateral epicondylitis) is one of several
overuse injuries that can affect your elbow. As you
might guess, playing tennis is one cause of tennis elbow
— but many other common activities can cause tennis
elbow, too.

• The pain of tennis elbow occurs primarily where the

tendons of your forearm muscles attach to the bony
prominence on the outside of your elbow (lateral
epicondyle). Pain can also spread into your forearm and
wrist.
Other treatments for tennis elbow are under
investigation. Some treatments being studied include
low-energy shock wave treatment, acupuncture,
botulinum toxin, orthotic devices, such as braces or
straps, and treatment with topical nitric oxide.
(MayoClinic.Com)
Pemilihan Titik :
• Titik nyeri lokal
• Titik ashi
• Titik kontralateral

Catatan :
• Dapat diberikan teknik encircling needling method
• Untuk kasus membandel dapat ditambahkan
elektroakupunktur atau pemanasan
TRIGGER FINGER
• Trigger finger, or trigger thumb, is a type of stenosing
tenosynovitis (specifically digital tenovaginitis stenosans) in
which the sheath around a tendon in a thumb or finger
becomes swollen, or a nodule forms on the tendon. In such
a condition, repetitive forceful use of a digit leads to
narrowing of the fibrous digital sheath in which it runs. This
leads to stenosis of the osseo-fibrous tunnel of the finger.
• The triggering is usually more pronounced in the morning, or
while gripping an object firmly.

• It is called trigger finger because when the finger unlocks, it

pops back suddenly, as if releasing a trigger on a gun.

• Trigger finger is usually idiopathic.

• Investigative treatment options with limited scientific
support include: non-steroidal anti-inflammatory drugs,
occupational or physical therapy, steroid iontophoresis
treatment, splinting, therapeutic ultrasound, phonophoresis
(ultrasound with an anti-inflammatory dexamethasone
cream), and Acupuncture.
Pemilihan Titik :
• Jiaji terkait
• Waiguan (TE 5) kedua sisi
• Yangxi (LI 5)
• Yangchi (TE 4)
• Yanggu (SI 5)
• Titik nyeri lokal
GASTRIC PAIN
Gastric pain is a common symptom including acute
gastritis, chronic gastritis, peptic ulcer, etc.

Pemilihan Titik :
• Zhongwan (Ren 12)
• Titik nyeri lokal
• Zusanli (ST 36)
• Neiguan
BACK PAIN
• Some people with low back pain report that
acupuncture helps relieve their symptoms. The National
Institutes of Health has found that acupuncture can be
an effective treatment for some types of chronic pain.
(MayoClinic.com)
Pemilihan Titik :
• Jiaji terkait
• Titik nyeri lokal
• Weichung (BL 40)
Anesthesiologist Emily Ratner administers
acupuncture treatment for back pain.
Ratner and Brenda Golianu co-direct the
new division of medical acupuncture, which
now provides both inpatient and outpatient
services at Stanford’s two hospitals.
POST HERPETIC NEURALGIA
• Postherpetic neuralgia (PHN) is a neuralgia caused by the
varicella zoster virus. Typically, the neuralgia is confined to a
dermatomic area of the skin and follows an outbreak of
herpes zoster (HZ, commonly known as shingles) in that
same dermatomic area. The neuralgia typically begins when
the HZ vesicles have crusted over and begun to heal, but it
can begin in the absence of HZ, in which case zoster sine
herpete is presumed (see Herpes zoster).
Pemilihan Titik :
• Jiaji terkait
• Titik ujung lesi
• Hegu LI 4)
• Quchi (LI 11)
DISMENOREA
• Dysmenorrhea refers to the syndrome of painful
menstruation.
• Primary dysmenorrhea occurs in the absence of pelvic
pathology, whereas secondary dysmenorrhea results from
identifiable organic diseases, most typically endometriosis,
uterine fibroids, uterine adenomyosis, or chronic pelvic
inflammatory disease.
• The prevalence of dysmenorrhea is estimated to be between
45 and 95% among reproductive-aged women. Although not
life threatening, dysmenorrhea can be debilitating and
psychologically taxing for many women and is one of the
leading causes of absenteeism from work and school.
Pemilihan Titik :

• Zhongji (Ren 3)
• Guanyuan (Ren 4)
• Sanyinjiao (SP 6)
• Ciliao (BL 32)
• Shenshu (BL 23)
KNEE PAIN
• Knee pain usually results from overuse, poor form during
physical activity, not warming up or cooling down, or
inadequate stretching.

• Simple causes of knee pain often clear up on their own with

self care.

• Being overweight can put you at greater risk for knee

problems.
Pemilihan Titik :
• Titik nyeri lokal
• Titik Ashi
• Zusanli (ST 36)
• Yanglingquan (GB 34)

Catatan :
• Bila terdapat faktor dingin, ditambahkan terapi
pemanasan
• Untuk nyeri/kaku pada lipat lutut, ditambahkan titik-
titik ashi pada daerah gluteal
HEEL PAIN
• Heel pain is one of the most common forms of foot pain in
adults. It often occurs as a result of daily activities and
exercise.

• The heel bone (calcaneus) is the largest bone in the foot

and the heel is the first part of the foot to contact the
ground during walking.
Pemilihan Titik :
• Xiaguan (ST 7)
• Titik nyeri lokal plantar atau
• Titik di kaki medial depan maleolus