Terapi Nyeri dengan Akupunktur

Fakultas Kedokteran Universitas Sebelas Maret Rumah Sakit Ortopedi Prof.Dr.R.Soeharso

Kuliah Tutorial Universitas Sebelas Maret Surakarta

KATA KUNCI

NYERI AKUPUNKTUR ANALGESIA

KATA KUNCI

NYERI AKUPUNKTUR ANALGESIA

Pain (IASP)
unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

International Association for Study of Pain, 1985

Sherwood, Human Physiology, 2004

Porth, Essentials of Pathophysiology, 2007

Jalur Nyeri Nociceptive Pathway

1. Tranduksi (transduction) : stimuli kuat mekanik, termik atau kimiawi diubah menjadi suatu aktivitas listrik 2. Transmisi (transmission) : penjalaran impuls melalui syaraf sensoris menyusul proses transduksi 3. Modulasi (modulation) : interaksi antara sistem analgesik endogen dengan input nyeri yang masuk ke cornu posterior medulla spinalis 4. Persepsi (perception) : hasil akhir dari proses interaksi yang komplek dan unik

the neuron that transmit pain impulses are component of sensory nervous system,

A and C fibers
Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

Porth, Essentials of Pathophysiology, 2007

Porth, Essentials of Pathophysiology, 2007

Porth, Essentials of Pathophysiology, 2007

Porth, Essentials of Pathophysiology, 2007

Nosisepsi
1. Transduksi
2. Transmisi

3. Modulasi
4. Persepsi

Sherwood, Human Physiology, 2004

B.E. Gould, Pathophysiology for the Health Professions, 2002

Ilmu Kedokteran Barat Conventional Western Medicine External projection (referred pain) Ilmu Pengobatan Timur Traditional Eastern Medicine Internal projection (acupuncture)

Ilmu Kedokteran Barat Conventional Western Medicine External projection (referred pain) Ilmu Pengobatan Timur Traditional Eastern Medicine Internal projection (acupuncture)

Maciocia, Diagnosis in Chinese Medicine, 2004

Ilmu Kedokteran Barat Conventional Western Medicine External projection (referred pain) Ilmu Pengobatan Timur Traditional Eastern Medicine Internal projection (acupuncture)

KATA KUNCI

NYERI AKUPUNKTUR ANALGESIA

Yin Yang symbol Taiji

Changing process of Universal Interrelates Interpenetrates Depends upon the other One appears within the other Opposing each other Revolving cycles of the one becoming the other Harmony Balanced Normal health Disharmony Imbalanced Disease/Pathologic

acupuncture
is the insertion of dry needles into the body at specially chosen sites for the treatment or prevention of symptoms and condition
Filshie,J,White,A,Medical Acupuncture, A Western Scientific Approach, 1998

Pembagian cun di berbagai bagian tubuh

all of the bodys organ are surrounded by

electrical field
Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

not only is there an electric field that surrounds the body but also one that flows within the body

Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

the energy within and surround each organ system can affect organ system

Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

SHENG Cycle Cycle for one element nourishes the next element Wood nourishes Fire Fire nourishes Earth Earth nourishes Metal Metal nourishes Water Water nourishes Wood KE Cycle Cycle for one element limits the other next element Wood limits Earth Fire limits Metal Earth limits Water Metal limits Wood Water limits Fire

these energy fields flowing within the body move through

meridians (channels)

Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

acupuncture points and meridian as

vessel for transport of bioelectric energy

Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

Acupoint Meridian

Acupoint Low resistant point (Croley, 1991)

2 kali papila dermis 2 kali gap junction

American Journal of Acupuncture, Vol 19 no.3, 1991

SKIN
epidermis dermis hair follicles skin pigments sensory nerve terminals capilairs venulas lymph vessels sweat glands sebaceus glands subcutaneus fat collagen fibers acupoint meridian

The acupuncture points to be located in a vertical column of loose connective tissue, surrounded by denser connective tissue of the skin. Within the column of loose connective tissue, a lymphatic trunk is coupled with an arteriole and vein The lymphovascular bundle is surrounded by a rich plexus of unmyelinated cholinergic nerve fibers The epidermis thins at the surface of the acupuncture points and there is modification of the collagen fibers
The basic morphologic structure of acupoints (Senelar, 1979)

Gambaran morfologis titik akupunktur

1. Luas permukaan kurang lebih 1-5 mm, dengan epidermis lebih tipis 2. Titik akupunktur biasanya terletak di lekuk yang terbentuk dari pertemuan otot gerak 3. Kebanyakan titik dapat diidentifikasi dengan palpasi, dirasakan pasien sebagai hipersensitif 4. Gambaran histologis sebagai kolom jaringan ikat longgar berisi arteriole, vena, pambuluh limfe, saraf bermyelin, dan banyak plexus saraf tak bermyelin, saraf otonom. Kolom dikelilingi jaringan ikat padat

Sifat biolistrik titik akupunktur

1. Titik akupunktur memiliki hambatan listrik lebih rendah kulit sekitar 2. Hambatan listrik di antara dua titik akupunktur dari meridian yang sama lebih rendah dibanding hambatan listrik dua titik akupunktur dari meridian yang berbeda 3. Titik akupunktur dan meridian simetris pada dua sisi (bilateral), tetapi tidak untuk yang berada di lines mediana anterior dan posterior tubuh

acu puncture
can be defined as the stimulation of a certain point or points on the surface of the body by the insertion of dry needles to modify the perception of pain, to normalize physiological functions, for the treatment of certain diseases

Acupoint Meridian

these energy fields flowing within the body move through

meridians (channels)

Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

acupuncture points and meridian as

vessel for transport of bioelectric energy

Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

what is the nature of channels ? how are the channels related to the effects of acupuncture ?
Lu Ding Hou, Muscle injuries and Pain involving Back and Limbs, 2000

Technetium 99 tracer studies

1. Technetium 99 injected into acupoints reveals linear spread topographically analogous to classically described acupuncture channels 2. Technetium 99 injected into non acupuncture points shows a centrifugal diffusion pattern 3. The rate of technetium 99 linear spread do not correlate with vascular or lymphatic circulation rates

Penelitian

Koosnadi Saputra
Teknesium perteknetat Sinar Gama KI-3 (Tayxi)

Meridian
Low Resistant Line (Nakatani, 1978) Primitive communication system (Oschman, 2000) Out of nervous system, vascular system, lymphatic system Has its own system

KATA KUNCI

NYERI AKUPUNKTUR ANALGESIA

all pain are related to Qi

pain means obstruction

Qi and blood are blocked

meridian (channels) circulates Blood and Qi links up Yin and Yang

Lu Ding Hou, Muscle injuries and Pain involving Back and Limbs, 2000

 Most acupuncture studies have concentrated in analgesia (Mann, 1973) Blocking of nociception Endogenous opioid must be the mechanism of acupuncture pain control Acupuncture as a neuromodulating input into CNS that can activate multiple analgesia systems in the spinal cord and brain Stimulating the endogenous pain suppresion system to release neurotransmitter
Filshie, J. Medical Acupuncture 1998

Mechanism of acupuncture stimulation

Via vascular (autonomic nerve system) Via sistem saraf (Neuroacupuncture) Via meridian

Penelitian

Litscher, Wang
Termografi PC-6 + LI-11

 309 acupoints : on or very closed to nerves 286 acupoints : on or very close to major blood vessels Sympathetic nerve also be involved (Goulden 1921) many acupoints correlate closely with trigger points (Travell & Simon1983) correspond with motor points of muscles (Liu, Varela & Oswald 1977)

Anonymous, The miracle of acupuncture, 1993

f MRI
1. Acupuncture has regionally specific, quantifiable effects on relevant brain structures 2. fMRI appears to be a valid tool for studying the CNS pathways affected by acupuncture

Kelompok perlakuan Kontrol Akupunktur Naloxon plus akupunktur Verapamil plus akupunktur conotoxin GVIA dosis rendah plus akupunktur conotoxin GVIA dosis menengah plus akupunktur
120

Kadar endorfin (ng/ml) 6.72 2.31 14.22 13.31 8.13 1.23 9.73 3.75 19.76 30.17 17.51 24.30 14.05 12.61

conotoxin GVIA dosis tinggi plus akupunktur

91.87 41.15 46.28 32.58

100

waktu respon (detik)

80

60

45.51 47.57

24.89 21.58

35.34 52.34

40

20.79 14.90

11.80 5.41

13.38 11.81

9.68 7.85

8.80 0.63

11.18 4.04

8.32 4.55

6.63 5.07

8.18 6.99

20

0
Kontrol Akp nalox+akp vera+akp ctx 2+akp ctx 30+akp ctx 90+akp

5.30 1.09

5.32 0.63

6.04 5.90

6.23 4.51

8.59 2.96

17.28 1.46

23.52 39.64

kelompok

menjilat

berdiri

meloncat

Penelitian Syarif Sudirman (2006) : Pengaruh Calcium blocker L dan N Pada Analgesia Akupunktur (pada Rattus norvegicus)

Activation of the key pain processing control areas

dACC : dorsal anterior cingulate cortex (attention focusing) cACC : caudal anterior cingulate cortex (perception of emotional component) rACC : rostral anterior cingulate cortex (modulation of pain)
Yun Taoma, Biomedical Acupuncture for Pain Management, 2005

Penelitian

Zang Hee Cho

fMRI LI-4 (Hegu)

Yun Taoma, Biomedical Acupuncture for Pain Management, 2005

 Cheng Pomeranz (1979) Han Ji Sheng (1998)

Cho, ZH (2001)
Mekanisme endorphinergic Dinetralkan dengan naloxon

there is relationship between

acupuncture points
and the

neuroendocrine system
and its role in pain control
Gellman, Acupuncture Treatment for Musculoskeletal Pain, 2002

Segmental acupuncture
Dermatom Neurotom Sclerotom Myotom Viscerotom

B.E. Gould, Pathophysiology for the Health Professions, 2002

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Filshie, Medical Acupuncture, 1998

Akupunktur disikapi oleh Profesi Ilmu Kedokteran Barat

Skeptis / menolak Ragu-ragu cenderung kurang percaya Penasaran mulai ingin tahu Mulai percaya (ainul-yakin) Mulai belajar (ilmul-yakin) Meneliti (haqqul-yakin)

Traditional Eastern Medicine or Conventional Western Medicine

?
which one will you choose ? which one is the best ?

although

eastern and western

system of medicine may seem diametrically opposed, they can be used together to complement each other and provide a more complete treatment program for the patient
(Harris Gellman, M.D, 2002)

akupunktur medik
pendekatan ilmiah mekanisme efek terapi akupunktur melalui pembuktian dengan metode kedokteran barat yang menghasilkan efek yang terukur, objektif, bisa diulang, model penelitian hewan coba

Penerapan akupunktur
Nyeri (akut, kronik, kanker) - di Bangsal Perawatan - di Poliklinik (Umum/Gigi/Nyeri/Paliatif) - di Kamar Operasi, Pulih sadar, ICU - di Instalasi Gawat Darurat - di Kamar Bersalin Penyalahgunaan obat narkotika/psikotropika Gangguan tumbuh kembang anak Anti aging Obesitas, kosmetik Rehabilitasi medik (pasca stroke, pasca spinal trauma) Sub fertilitas/infertilitas/IVF (In Vitro Fertilization) Ilmu Kedokteran Olahraga

KepMenKesRI No. 1076/MENKES/SK/VII/2003 PENYELENGGARAAN PENGOBATAN TRADISIONAL PerMenKesRI No. 1186/Menkes/Per/XI/1996 PEMANFAATAN AKUPUNKTUR DI SARANA PELAYANAN KESEHATAN

KepMenKesRI No. 1227/Menkes/SK/VIII/2003 TENAGA AKUPUNKTUR

International Standard Acupuncture Nomenclature (1984) Guidelines for Clinical Research on Acupuncture WHO Regional Publication Western Pacific No.15 (1995) Guidelines on Basic Training and Safety in Acupuncture (1999)

CONCLUSION

EAST AND WEST PROVIDE THE BEST

Matur Nuwun Terima Kasih Thank You Xie-Xie