PESQUISA – ABSTRACTS

ANESTESIA POR ACUPUNTURA (bIblIOTECA vIRTUAl)

Em 1958, a acupuntura foi utilizada para dar analgesia nas trocas de curativos, posteriormente nos pós-operatórios das tonsilectomias.
Em 1960, passaram a aplicar a anestesia nas pneumectomias, usando até 87 agulhas manipuladas por 3 acupunturistas. O número de pontos foi
sendo reduzido através de pesquisas em pacientes e em voluntários para 29 pontos, sendo 17 de meridianos Iang e 12 de meridianos In. O ponto
IG4 foi considerado o mais eficaz entre os pontos Iang e aumenta o limiar da dor na cabeça e no dorso. O ponto BP4 foi considerado o mais eficaz
entre os pontos In, aumenta o limiar da dor na face anterior do tronco. Nos primeiros anos, os cirurgiões tinham que esperar 60min para começar a
operação.Os pontos de acupuntura, segundo as localizações e efeitos neurofisiológicos, podem ser agrupados em quatro tipos (GUNN, 1977):I -
Ponto Motor, localizado na banda muscular transversa ou também chamada zona de enervação do músculo, os estímulos seguem pelas
terminações anuloespirais e fibras Ia. Ex.: IG4, E36, IG11.II - Pontos localizados nos cruzamentos de nervos na linha mediana do corpo. Ex.: Vaso
Governador e Vaso Concepção.III - Pontos localizados sobre nervos ou plexos nervosos. Ex.: CS6, B40.IV - Pontos localizados na junção
tendino-muscular, os estímulos são captados pelos órgãos tendinosos de Golgi e seguem pelas fibras Ib. Ex.: TA10, E36, B57.
PONTOS IMPORTANTES PARA ANALGESIAFutu (IG18) - Localizado na face lateral do pescoço, no ponto médio da margem posterior
do musculo esternocleidomastoídeo.Anatomia: mm. esplênios, esternocleidomastoídeo, e na profundidade, a origem do m. elevador da
omoplata.Grande n. auricular saindo de C2-C5, n. cutâneo cervical e n. ocipital menor.Chunliao (ID18) - Diretamente abaixo do canto externo do
olho, na borda inferior do osso zigomático, no mesmo nível das narinas.Anatomia: origem do masseter, no meio do m. zigomático.
N. facial e ramo infraorbitário do trigêmeo.
Wushu (VB27) - 3 polegadas abaixo do umbigo e 1 polegada para frente da espinha ilíaca ântero-superior. Anatomia: mm. oblíquo
interno, oblíquo externo e tranverso do abdomen.
N. iliohipogástrico saindo de L1.Tzuliao (B32) - No 2º forame sacral e na parte ântero-inferior da espinha ilíaca
póstero-superior.Anatomia: origem do m. glúteo maior.Ramo posterior do 2º n. sacral.Mingmen (VG4) - Entre os processos espinhosos das
vértebras L2 e L3.Anatomia: fáscia lombodorsal, ligamentos supraespinhoso e interespinhoso.Ramo posterior do 2º n. lombar.Neikuan (CS6) - 2
polegadas acima da prega cutânea do punho, na face anterior do antebraço.Anatomia: entre os tendões flexor radial do carpo e palmar longo, nos
músculos flexores superficial e profundo dos dedos.Nn. de C6 a T1 - superficialmente: n. cutâneo medial do antebraço; profundamente: n. mediano
e n. interósseo volar.Hoku (IG4) - No dorso da mão, entre o 1º e 2º metacarpiano, no ponto médio do 2º metacarpiano.Anatomia: mm. 1º interósseo
dorsal e adutor do polegar.Nn. de C5 a T1 - ramo do n. radial e ramo do n. digital volar próprio do n. mediano.Sanyanglo (TA8) - 4 polegadas acima
da prega cutânea do punho, no dorso do antebraço, entre rádio e ulna.
Anatomia: m. extensor comum dos dedos.Nn. C5 a T1 - n. cutâneo dorsal do antebraço na camada superficial e n. interósseo dorsal do
antebraço na camada profunda.Tsusanli (E36) - 3 polegadas abaixo da tuberosidade da tíbia, na face lateral do m. tibial anterior.Anatomia: entre m.
tibial anterior e m. extensor longo dos dedos.Nn. de L4 a S1 - Na camada superficial: n. cutâneo sural lateral e ramo cutâneo do n. safeno; na
camada profunda: n. peroneiro profundo.Kuangming (VB37) - 5 polegadas acima do maléolo lateral, à frente do perônio.Anatomia: entre m.
extensor longo dos dedos e m. peroneiro curto.Nn. de L4 a S1 - n. peroneiro superficial e n. peroneiro profundo.Sanyinchiao (BP6) - 3 polegadas
acima do maléolo medial, imediatamente atrás da tíbia.Anatomia: m. abdutor do hálux.Nn. de L3 a S1 - ramo do n. ciático de L3-L4 e ramo do n.
peroneiro superficial de L4-S1.
TÉCNICA E SELEÇÃO DOS PONTOS1 - Método de pontos locais, adjacentes e distantes: os pontos devem pertencer a meridianos
que atravessam ou se aproximam da área cirúrgica, e que tenham relação com os tecidos, órgãos ou vísceras a serem operados.Os pontos devem
pertencer ao mesmo metâmero ou a metâmeros adjacentes àquele da área cirúrgica.2 - Métodos de pontos auriculares: utilizar os pontos
Shen-Men, SNV e Subcórtex; acrescentar os pontos correspondentes à área cirúrgica; estimular alguns pontos de acordo com a teoria das Cinco
Transmutações (Pulmão para pele, Rim para ossos e ouvido, Fígado para olhos, Baço para músculos).Colocação precisa das agulhas nos pontos
(utilizar talvez os detectores eletrônicos).Estimulação manual até obter TE CHI. Estimulação manual ou elétrica durante a cirurgia, aumentando os
estímulos nas fases mais dolorosas (pele, pleura, perióstio, peritônio).Pontos Locais: agulhas paraincisionais e subcutâneas, em torno de 1,5cm da
incisão, estimulação de 50-100Hz.Pontos distantes: 2 a 5Hz.Pontos auriculares: frequência mais elevada que a dos pontos distantes.A voltagem e
a corrente devem ser a máxima suportável pelo paciente, e aumentada periodicamente de acordo com o fenômeno da adaptação do paciente (ou
mudar para frequências moduladas).O formato das ondas não parece ser tão importante, entretanto, os aparelhos mais conhecidos (G6805, 71-3)
apresentam impulsos rápidos (microsegundos) com voltagem negativa elevada (400V).Período de latência de 15-20min.Seleção dos pacientes:
testar TE CHI, avaliar a inibição simpática, intradermoreação com 0,1ml de adrenalina 1/1000.Ketamina e diazepínicos diminuem o efeito da
acupuntura; Plasil (10mg EV ou 10-20mg IM) aumenta
o efeito.Pré-anestésicos devem ser recomendados como o fentanil ou o droperidol. Durante a cirurgia, podem ser utilizados petidina,
novalgina ou aspirina, xilocaína e adrenalina. Xilocaína para analgesia em alguns pontos dolorosos e para bloquear reflexos vago-simpáticos.
Adrenalina para diminuir o sangramento inicial.Evitar o uso de cauterização elétrica.Importante verificar a fixação de agulhas e eletrodos.
EXEMPLOS DE SELEÇÃO DOS PONTOS Craniotomia frontal : ID18 homolateral Intervenções dentárias: IG4, AE36, E44
(mandibulares), R7 (maxilares) e pontos locais Tiroidectomia: IG18 bilateral Toracotomia: IG14 até IG15 unilateral; TA8 unilateral.
Cirugias Cardíacas: P7 e CS6 bilateral; pontos auriculares: cervical, tórax, pulmão, rim à esquerda
CS6, P7, BP4 e R6 bilateral Gastrectomia: E36 e E37 bilateral Apendicectomia, Herniorrafia: VB27, E25 e E36, Vei-Ma Histerectomia:
B32 bilateral, VG2 e VG4 Cesariana: BP6 e Paraincisionais
BP6, F3 e E39
BP6, CS6 e E36
Ligadura de Trompas: BP6 unilateral Paraincisionais VG26, VC24, B32 bilaterais
Curetagem: útero (trajeto longo) e SNV unilateral
Cardioversão: IG4 e CS6 (Niboyet)
DESVANTAGENSNão atua sobre os reflexos fisiológicos ou neurovegetativos, sobre a consciência, o tônus muscular, e as sensações
de tato, pressão e tração;Analgesia nem sempre completa, relaxamento muscular insuficiente, reflexos vago-simpáticos presentes; exige cirugiões
hábeis; não serve para cirurgias extensas, longas, profundas ou exploratórias; não serve para urgências; pacientes com cicatrizes extensas não
respondem tão bem.
VANTAGENSModifica a sensibilidade térmica, aumenta o limiar da dor. Não altera PA, P, FR etc.; boa hemostasia; aumenta defesa
imunológica;O paciente pode colaborar nos casos de neurocirurgia, estrabismo, tiroidectomia, laringectomia, cirurgias vertebrais, plástica de mão
ou face;Não necessita de entubação endotraqueal em algumas cirurgias cardíacas e torácicas; cicatrização boa;Ausência de
HIPERSENSIBILIDADE a drogas; pós-operatório ESPETACULAR; econômico, simples, seguro e razoavelmente eficiente.
INDICAÇÕESHipersensibilidade a drogas, zonas rurais, grandes queimados, idosos, graves (cardio, pneumo, hepato ou nefropatias,
choque);Procedimentos "simples": curetagem, cstoscopia, arteriografia, cardioversão, sedação para pequenas cirurgias; melhorar pós-operatório;
diminuir a necessidade do anestésico.
C O N T R A I N D I C A Ç Õ E S
Hipertensos > 20x10, cirurgias abdominais grandes.
ALGUNS DADOS NEUROFISIOLÓGICOS
Analgesia por acupuntura é essencialmente um método para submeter os impulsos dolorosos a uma série de processos de seleção,
filtração, e inibição no sistema nervoso central de modo que a mensagem dolorosa seja reduzida ou impedida de atingir certo nível de consciência.
Isso depende da interação e integração das diferentes entradas sensoriais no sistema nervoso central. Um tipo de impulso sensorial pode ser
inibido por outro tipo de impulso sensorial vindo de qualquer outra parte do corpo. Por exemplo, a dor pode ser inibida por mensagem, pressão,
toque, contração muscular, vibrações etc. O fenômeno da inibição é possível quando a intensidade do estímulo atinja o limiar das fibras de
tamanho médio. Mas um estímulo muito forte que excita as fibras finas pode facilitar as descargas nociceptivas neuronais.
O PONTO DE ACUPUNTURA Em 1959, a Universidade de Xangai realizou preparações histológicas de 324 pontos clássicos de
acupuntura constatando que em 323 deles havia agrupamentos de terminações nervosas dentro de 5mm de cada ponto. Em 1975, Fleck,
estudando potenciais de ação provocados por estímulo de ponto de acupuntura, verificou que eram idênticos àqueles provocados diretamente no
nervo mediano (registrado em unidades múltiplas). Em 1993, Takeshigue e col. demonstraram que os potenciais evocados no sistema nervoso
central (SNC) vindos do ponto de acupuntura ou do nervo correspondente ao ponto, eram idênticos. Desde os trabalhos de Nakatani (1950) e de
Niboyet (1960), sabe-se que os pontos de acupuntura correspondem a regiões da pele cuja resistência era mais baixa que a área vizinha. Isto é
demonstrável inclusive em cadáveres conservados mais de 6 meses em formol. Em 1985, Ciszek e col. encontraram nesses pontos de baixa
resistência elétrica concentração de terminações nervosas livres maior no centro do que na periferia. Em 1988, Heine revelou que desses pontos
saem fibras nervosas em direção à fáscia corporal superficial ou para a camada musculoaponeurótica. Estes fatos permitem concluir que um ponto
de acupuntura é uma região da pele em que é grande a concentração de terminações sensoriais e sua estimulação possibilita acesso direto ao
SNC. As vias aferente e eferente da Acupuntura Desde 1975 muitos trabalhos vêm mostrando que os efeitos analgésicos da acupuntura são
intermediados pelo SNC. Diversos pesquisadores chineses e ocidentais descobriram que a acupuntura provoca em diversas regiões do SNC
potenciais evocados, assim como aumento da atividade de neurônios unitários e multiunitários. Embora as vias nervosas implicadas na acupuntura
estejam já razoavelmente bem definidas, a maior parte dos efeitos terapêuticos não foi ainda explicada convenientemente. As descargas elétricas
das células do corno dorsal induzidas por estimulação das fibras C surais ou por estímulos nocivos podem ser inibidas por estimulação das fibras
Abgd. Como aplicação clínica, a causalgia pode ser aliviada por estímulo seletivo de fibras largas de nervos periféricos. Estímulo elétrico
percutâneo ou transcutâneo, ou a estimulação manual de pontos proximais a uma ferida pode facilitar a troca de curativo. Os efeitos inibitórios são
mais intensos utilizando pontos ou nervos do mesmo segmento ou adjacentes da medula espinhal. As vias da acupuntura diferem segundo o
estímulo das terminações nervosas, seja de baixa (1-15Hz) ou alta (mais de 100Hz) frequência. Por exemplo, na anestesia por acupuntura, para as
agulhas próximas à incisão, usa-se estimulação de 50Hz e para os pontos distantes, de 2 a 5Hz. A maioria das terapias por acupuntura utiliza
baixa frequência. Omura relata que estímulos elétricos > 6Hz altera a microcirculação, entretanto, a frequência que ele recomenda é aquela
sincronizada com o coração, isto é, 1 a 2Hz. O estímulo elétrico de baixa frequência provoca impulsos nervosos que ascendem ao SNC pelo
cordão ântero-lateral contralateral da medula espinhal, núcleo reticulogigantocelular da formação reticular e núcleo magno da rafe até a região
dorsal do extrato cinzento periaquedutal do mesencéfalo, em sua região dorsal. Esse é o ponto de partida para o que se considera a via aferente
da acupuntura. Do extrato cinzento periaquedutal dorsal a via aferente implicada nos efeitos da acupuntura dirige-se ao hipotálamo anterior,
hipotálamo posterior e núcleo centromediano do tálamo. Do hipotálamo posterior partes dessa via ascendem aos núcleos septais laterais, fascículo
do cíngulo, hipocampo dorsal e trato habênulo-interpeduncular. Da região medial do núcleo centromediano há contingentes que ascendem ao
hipocampo dorsal. Do hipotálamo lateral, alguns ramos dirigem-se aos núcleos septais laterais, enquanto outros ativam a eminência média (que
faz parte do sistema liberador de bendorfinas). Uma via liga os núcleos septais laterais ao trato habênulo-interpeduncular.
Como se vê, a via aferente da acupuntura se abre em vias divergentes adiante do extrato cinzento periaquedutal dorsal e convergentes
para o trato habênulo-interpeduncular. Daí, as informações seguem para o hipotálamo anterior e deste para região medial do núcleo arqueado
hipotalâmico, onde ela termina. A partir da região posterior do núcleo arqueado hipotalâmico, o estímulo da acupuntura ativa o sistema
descendente inibidor da dor. A via que se inicia na porção posterior do núcleo arqueado hipotalâmico desce para o núcleo ventromediano do
hipotálamo, por uma via mediada pela dopamina. A partir daí, essa via eferente divide-se em duas: uma via noradrenérgica que desce para o
núcleo reticuloparagigantocelular - e provavelmente também para o núcleo reticulogigantocelular - e outra, mediada pela serotonina, que desce
pelo extrato cinzento periaquedutal (região ventral) e pelo núcleo magno da rafe; as duas vias terminam no funículo dorsolateral da medula
espinhal, onde exercem seu efeito inibidor. O estudo eletrofisiológico dos núcleos centrais implicados na acupuntura revela as características
mencionadas abaixo:
Potenciais de ação evocados pela eletroestimulação de baixa frequência (1 a 4Hz) do ponto de acupuntura ou após injeção
intraperitonial de morfina na dose de 0,5mg/kg são semelhantes e ativam neurônios dos sistema descendente inibidor da dor. A injeção
intraperitonial de naloxona ou de antisoro de b-endorfina no terceiro ventrículo bloqueia o efeito desses estímulos. O Levalorfan também bloqueia
um pouco a analgesia.
A eletroestimulação direta dos núcleos centrais com a frequência de 80Hz produz analgesia semelhante à acupuntura, isto é, com
tempo de analgesia que se prolonga após o término do estímulo. A hipofisectomia bloqueia essa analgesia.
A eletroestimulação direta dos núcleos que fazem parte do sistema descendente inibidor da dor com frequência de 80Hz provoca
analgesia mas, distintamente do que ocorre com os núcleos da via aferente, o tempo de analgesia não se prolonga após o término do estímulo;
tampouco tal analgesia é afetada pela hipofisectomia nem por injeção intraperitonial de naloxona ou de anti-soro de b-endorfina no terceiro
ventrículo.
A lesão de alguns núcleos do SNC bloqueia a analgesia produzida por acupuntura ou por estímulo do núcleos localizados em níveis
inferiores.
VIAS DE LIBERAÇÃO DE b-ENDORFINAS Desde a descoberta das b-endorfinas por Hughes e col. em 1975, diversos pesquisadores
mostraram que há aumento de b-endorfinas no líquido cefaloraquidiano (LCR) durante a estimulação de pontos de acupuntura. Demonstrou-se
também que a analgesia provocada pela acupuntura de baixa frequência é parcialmente abolida pela naloxona, antagonista das endorfinas, ou por
microinjeção de anti-soro de bendorfina no terceiro ventrículo. Por intermédio de dois centros da via aferente, o hipotálamo lateral e
 o núcleo arqueado hipotalâmico medial, são ativadas a área pré-optica e a eminência média. O estímulo direto dessas áreas não
provoca analgesia. A eminência média ativa a liberação de bendorfinas pela hipófise. As b-endorfinas atuam facilitando pré-sinapticamente as vias
entre as regiões medial e posterior do núcleo arqueado hipotalâmico, o que é intermediado pela dopamina. O estímulo dos pontos de acupuntura
aumenta a quantidade de substâncias com ação morfínica em vários locais do sistema nervoso central. As endorfinas aumentam no cérebro. A
fração I da endorfina aumentam no LCR. Existe liberação de endorfinas na substância cinzenta periaqueductal por vias que saem do núcleo
caudado. A estimulação elétrica dos pontos transfere as endorfinas da hipófise para a corrente sanguínea. A dexametasona diminui o conteúdo
das endorfinas da hipófise. A adrenalectomia bilateral aumenta a quantidade de endorfinas na hipófise e aumenta o efeito analgésico da
acupuntura. Um nível bom de 5 HT no núcleo magno da raphe é importante para haver o efeito da acupuntura. A acupuntura diminui a quantidade
de Noradrenalina no tecido cerebral. O propanolol inibe parcialmente o efeito da acupuntura.
A procaína aplicada profundamente no ponto de acupuntura inibe o efeito da acupuntura. Em paraplégicos ou hemiplégicos, o efeito da
acupuntura também não se manifesta. Pelo cruzamento das carótidas entre dois animais, a acupuntura em um animal aumenta o limiar da dor no
outro animal. O efeito da acupuntura demora mais para se manifestar e demora mais para desaparecer nos centros nervosos superiores que na
medula espinhal. Provavelmente a medula espinhal é uma área de reflexos para a dor e que a integração da sensação da dor seja realizada pelos
centros superiores. Assim, o efeito dos pontos locais e adjacentes é elaborado na medula espinhal e a ação dos pontos distantes, em níveis
talâmicos e telencefálicos. As pesquisas mais recentes mostram que o estímulo dos pontos ativa terminações sensoriais cutâneas e que as
informações resultantes disso acionam pelo menos duas (provavelmente várias) vias neurais centrais. As vias diferem se o estímulo é de baixa ou
alta frequência, o estímulo de baixa frequência aciona uma via dependente de b-endorfinas. Sabe-se que a via acionada por estímulos de alta
frequência não depende de opióides, pois não resulta em analgesia reversível por naloxona. Resta ainda muito a pesquisar com outros núcleos
além dos que correspondem à via clássica conhecida.

ANALGESIA POR ACUPUNTURA – CONDIÇÕES PÓS-OPERATÓRIAS

CHEN_SC; LU SN; LAI CT; JEAN JY; HSIAO CL; HSU PT (1991) Aqueous AP for postoperative pain: a
matched controlled trial. Kaohsiung i Hsueh Ko Hsueh Tsa Chih Kaohsiung - J of Med Sci Sep 7(9):466-470. Dept of
Int Med, Kaohsiung Med Coll, Taiwan, ROC.
FAURE-ANTONIETTI_F; ANTONIETTI C; ESTANOVE S; NINET J; VIGNERON M; CHAMPSAUR G (1991)
Treatment using traditional AP of early scapulohumeral pains after heart surgery. Cahiers d' Anaesthesiologie
39(8):537-540. In French. Service de chirurgie thoracique et cardiovasculaire C, Hôpital cardiologique, Lyon.
GEMMA_M; BRICCHI-M; GIANNINI-A; COFFANO-B; GRANDI-L; QUIRICO-P (1993) AP accelerates
recovery from general anaesthesia [letter]. Can J Anaesth Dec 40(12):1224-1245.
GRABOW_L (1994) Controlled study of the analgetic effectivity of AP. Arzneimittelforschung Apr
44(4):554-558. Zentrale Abteilung für Anästhesiologie und Intensivmedizin, Evangelische und Johanniter
Krankenanstalten, Duisburg, Germany.
LEWIS_SM; CLELLAND JA; KNOWLES CJ; JACKSON JR; DIMICK AR (1990) Effects of Ear-AP-like TENS
on pain levels after wound care in patients with burns: a pilot study. J of Burn Care and Rehab Jul-Aug
11(4):322-329.
MOLDOVAN_C1 ET AL (1986) EAP Treatment Method for Arm Oedema after Surgery for Breast Cancer.
International Med AP Conference, London, UK, May 4-8. Inst of Oncology, Bucharest, Romania.
TSIBULIAK_VN; ALISOV AP; SHATROVA VP (1995) [APA and analgesic TENS in the early postoperative
period]. Anesteziol Reanimatol Mar-Apr 2:93-97.
O efeito analgésico da AP é muito bem documentado, aquapuntura, ou injeção em pontos, é um método
moderno convenientemente modificado.
This matched controlled trial was carried out to evaluate the effects of aqueous AP in postoperative pain
control. A total of 12 patients were selected as age-, sex- and operative-style-matched controls. In the AP-treatment
group when patients had regained consciousness after operative anaesthesia, 2-5 ml of 20% glucose solution was
injected into LI04 and GB34. Pain intensity was scored on verbal assessment, sleep disturbance and use of narcotics.
Compared with the control group, AP significantly reduced the intensity of postoperative pain, and the amounts and
frequency of narcotics used, especially in the first 12 h post-op. Aqueous AP is a convenient and effective way to
control postoperative pain.
The purpose of this study was to test the efficacy of traditional Chinese AP to treat scapulohumeral pain during
the early stage after heart surgery, by simple AP (without needle stimulation) of points not related anatomically or
metamerically with the scapulohumeral joint. Reduction of pain and angular gain were almost immediate, durable,
measurable and reproducible. This is explained by possible effects of AP on articular sympathetic mechanoreceptors,
then suppressing reflex muscular contractions due to intraoperative postural constraints.
2 methods were used to test the analgesic effectivity of AP: 1. as a method of postoperative pain therapy
several analgesic medications were compared with AP; 2. extracorporeal shockwave lithotripsy (ESWL) was used as a
clinical algesimeter to test the analgesic effect of analgesic medications and AP to a controlled pain stimulus. In both
groups the analgesic effectivity was placebo controlled. Both methods showed equally that the analgesic effect of AP is
similar to that of the placebo group. Thus AP is not a generally useful form to treat acute pain. However, in every
examined population, a minority is completely satisfied with AP as sole treatment of pain. The secret of AP probably lies
in the selection of patients sensitive to AP. Under controlled conditions, postoperative wound pain may be an
algesimeter analagous to ESWL. This may be important.
This study tested the hypothesis that Ear-AP-like TENS would significantly reduce the pain experienced by
patients with burns immediately after wound debridement, other wound care, and dressing changes. Subjects were 11
inpatients at the Univ of Alabama Hospital Burn Unit. A 2-period crossover design was used; each patient received one
experimental treatment consisting of bilateral AP-like TENS to 6 Earpoints and one control treatment consisting of a
placebo pill. The Visual Analogue Scale was used to measure pain and was used immediately before and after
treatments and at 15, 30, and 60 min after treatment. A 2-factor repeated measures ANOVA indicated significant effects
of measurement time (p<.001) and treatment by time (p=0.002). Post hoc analysis showed significant differences
(p<.05) between experimental and control conditions at all times after treatment but not at pretreatment baseline.
Ear-AP-like TENS was an effective pain management technique in patients with burns.
Upper limb oedema (bloating from retention of water) occurs after surgery for breast cancer in circa 83% of the
cases. Existing means have relatively limited efficiency. This study presents a treatment method with EAP (AP in which
weak electrical currents are sent through the needles) on a group of 21 patients with upper limb oedema. Treatment
response was based on objective criteria including clinical and thermoelectric measurements. Complete recovery from
oedemas was obtained in 33% of the cases, while partial recovery was seen in 43% of the cases. No response was
seen in 24%.
Efficacies of 2 methods of non-drug analgesia: AP- (1000 cases) and TENS- (91 cases) analgesia, as well as
of narcotic analgesics omnopon and promedol (229 cases) were compared in the immediate and early postoperative
period. In 229 cases AP was used to treat other functional complications of the postoperative period. The efficacies of
the methods in question were assessed by formalized verbal estimation scales. Narcotic analgesics provided adequate
analgesia in 75-79% of patients, TENS in 61-64%, AP in 50% of patients. AP, though less effective than narcotic
analgesics, helped arrest or noticeably alleviate the severity of such postoperative complications as reflex retention of
the urine, impairment of the drainage function of the bronchi, intestinal paresis, bronchial asthma, vomiting, nausea,
pain or itching in the stoma, chill, hyperthermia in 43-81% of cases. Conclusion: An integrated approach (combined use
of drugs and non-drug methods of analgesia) is desirable in the management of postoperative pain.

ACUPUNTURA ANALGÉSICA CUTÂNEA

Bossut_DFB; Stromberg MW; Malven PV (1986) EAP-analgesia in sheep: measurement of cutaneous pain
thresholds and plasma concentrations of prolactin and beta-endorphin immunoreactivity. Am J Vet Res Mar
47(3):669-676.
Brockhaus_A; Elger CE (1990) Hypalgesic efficacy of AP on experimental pain in man: Comparison of
laser-AP and needle AP. Pain Nov 43(2):181-185. Universitäts-Nervenklinik, Epileptologie, Bonn, Germany.
Yang_Q (1993) AP treatment of 139 cases of neurodermatitis. JTCM Mar 13(1):3-4. Tian Men First People's
Hospital, Hubei Province, PRC.
The analgesic effect of AP on cutaneous heat stimuli of 43oC was evaluated in a controlled study with healthy
volunteers. Under double-blind conditions, helium-neon laser-AP was used on 39 probationers. Bilateral LI04 and
Jianqian (Extra) were irradiated for 1 min each. 40 probationers were needled at bilateral LI04 under single-blind
conditions. Pain threshold was measured as the time (in ms) that the probationers needed to perceive the cutaneous
heat stimulus of 43oC. The painful stimulus was generated by a computer-controlled standardized procedure. The
Wilcoxon test was used for the statistical evaluation. Laser-AP did not change the pain threshold. Needle AP did,
however, increase the pain threshold compared with the initial value (alpha=.1%). The difference compared with the
control group, where a placebo point was needled, was also significant (alpha=5%). This controlled experimental study
proves the analgesic effect of needle AP on painful heat stimuli. Laser-AP had no effect on pain threshold in this study.

ACUPUNTURA, TENS E ELETROESTIMULAÇÃO NO CONTROLE DA DOR

LEUNG CY, SPOEREL WE. Effect of auriculo-acupuncture on pain. Am J Chin Med 1974 Jul;2(3):247-260.
MELZACK R. Prolonged relief of pain by brief, intense transcutaneous somatic stimulation. Pain 1975
Dec;1(4):357-373.
The purpose of this study was to examine the effects of brief, intense transcutaneous electrical stimulations at
trigger points or acupuncture points on severe clinical pain. The McGill Pain Questionnaire was used to measure the
change in pain quality and intensity produced by stimulation. The data indicate that the procedure provides a powerful
method for the control of some forms of severe pathological pain. The average pain decrease during stimulation
sessions was 75% for pain due to peripheral nerve injury, 66% for phantom limb pain, 62% for shoulder-arm pain, and
60% for low-back pain. The duration of relief frequently outlasted the period of stimulation by several hours, occasionally
for days or weeks. Different patterns of the amount and duration of pain relief were observed. Daily stimulation carried
out at home by the patient sometimes provided gradually increasing relief over periods of weeks or months. Control
experiments, which included two forms of placebo stimulation, showed that brief, intense electrical stimulation is
significantly more effective than placebo contributions. Possible neural mechanisms that underlie these patterns of pain
relief by brief, intense stimulation are discussed.
LAITINEN L. Placement of electrodes in transcutaneous stimulation for chronic pain. [Article in French].
Neurochirurgie 1976 Sep;22(5):517-526.
Forty-six patients with chronic pain were treated with transcutaneous nerve stimulation (TNS). If there were any
signs of sensory loss in the pain area, the electrodes were placed on the healthy side of the body. The effect of TNS
was assessed quantitatively. After 9 months of repeated TNS, on average, the total pain score had improved by 39%.
The subjective intensity of the pain, the frequency of pain and the need for analgesics had diminished by 46-47%. In
those conditions in which total improvement was better than the mean (phantom limb pain, 65%; zoster neuralgia, 56%;
thalamic pain, 45%), the healthy side of the body had been stimulated. In those in which the painful area had been
stimulated (cancer pain, 32%; low back pain, 32%; brachialgia, 15%), the beneficial effect did not reach the mean for
the whole series. This suggests that TNS of the healthy side of the body may give better long-term improvement than
stimulation of the painful area. A theory of chronic pain and the mechanism of TNS is presented.
LEVINE JD, GORMLEY J, FIELDS HL. Observations on the analgesic effects of needle puncture
(acupuncture). Pain 1976 Jun;2(2):149-159.
The present study was undertaken in order to investigate the analgesic effect of needle puncture in a small
self-selected group of patients with chronic or acute pain, and to examine the factors which determine success or failure
of this treatment modality. We have found that in chronic painful conditions, needle puncture may be very effective in
producing at least transient analgesia. It also can produce permanent relief of acute (self-limited) pains. Needle
puncture was not helpful in the management of pain resulting from nerve damage. High score on psychometric
indicators of anxiety and depression is a significant predictor os successful needle puncture analgesia in patients with
chronic pain. Comparison of our results to studies of counterirritation indicate that the analgesia produced by needle
puncture involves a mechanism similar to that of counterirritation-induced analgesia.
GAWLOWSKI J Development of neurosurgical treatment of chronic painful syndromes. [Article in Polish].
Pol Tyg Lek 1976 Nov 1;31(44):1901-1904
KHROMOV BM Acupuncture in surgery. [Article in Russian]. Vestn Khir 1978 Feb;120(2):135-138.
ANANI A, KORNER L. Discrimination of phantom hand sensations elicited by afferent electrical nerve
stimulation in below-elbow amputees. Med Prog Technol 1979 Jun 15;6(3):131-135.
The necessity for a sensory feedback system that would enhance patient acceptability of motorized hand
prostheses is now generally acknowledged. Afferent electrical stimulation of the nerves in the amputation stump can
convey sensory feedback from prostheses with the advantage of eliciting sensations in the phantom image of the lost
hand. Experiments with percutaneous nerve stimulation of the amputation stump in below-elbow amputees showed that
with stable electrode conditions, amplitude modulated stimulation was better than frequency modulated stimulation in
terms of accuracy, delay, and transinformation both with intermittent and uninterrupted stimulation. With unstable
electrode conditions, different results were noticed, since amplitude modulated stimulation is very sensitive even to
minor changes in electrode position. It is concluded that afferent electrical nerve stimulation with adequate training and
stable electrodes had characteristics of accuracy, transinformation and delay which are good enough to make it a
suitable method of conveying information in a prosthesis feedback system.
MILANI L, ROCCIA L. Unusual use of reflexotherapeutic technics for control of pain in cases of phantom
limb. Spinal and supraspinal theory. [Article in Italian]. Minerva Med 1979 Dec 15;70(56):3843-3851.
Treatment of selected cases of amputees suffering from phantom-limbs pains by means of unusual techniques
of reflexotherapy is reported. Nose, hand and foot acupuncture and classical auricolotherapy demonstrate in the
patients here reported the beneficial effect of these methods. Nosologic, pathologic, clinic results and the anatomo
functional mechanisms through which the therapeutic action of reflexoterapy can be explained are discussed. Spinal
and trigeminal-reticulo-spinal pathways (central biasing mechanism) are postulated as inhibitory control system for
somatic afferences.
MONGA TN, JAKSIC T. Acupuncture in phantom limb pain. Arch Phys Med Rehabil 1981
May;62(5):229-231.
 A case of a 36-year-old man, with a history of traumatic amputation below the elbow on the left side, resulting
in intractable phantom limb pain, is described. The patient failed to respond to a variety of medications including several
analgesics, tranquilizers, and a beta-blocker. Other extended series of conventional treatment modalities, which
included stellate ganglion and peripheral nerve blocks and neuromal excision with the anterior transposition of the ulnar
nerve, did not relieve the pain. Acupuncture was then attempted with the subjective relief of phantom limb pain and the
objective result that the patient could wear a prosthesis.
AFIFI AK. Pain: a review. Middle East J Anaesthesiol 1981 Jun;6(2):69-89
ZANINI F.. Current role of acupuncture in analgesic therapy. [Article in Italian]. Minerva Med 1983 Apr
21;74(17):961-967
After a brief introduction dealing with the great development of acupuncture in management of various painful
conditions in the West today, its increased importance, use and role in acute and chronic pain, benign and intractable
pain, are discussed. Recent acquisitions about known and yet unknown neurophysiological parameters (evoked cns
potentials, endorphines, action of acupuncture in "regulation" of many functions--so called homeostasis--milieu) in
connection with good pain relief properties of acupuncture, are referred. The main methods of acupuncture in pain
treatment (acupuncture as reflexotherapy--so called electroacupuncture and the very effective auriculotherapy, in
comparison with traditional acupuncture as "regulating" method of homeostasis and others minor methods, with our
casuistry and positive results in 724 cases of various pain conditions are stressed. Own conclusions about the positive
results and the great significance of physician-patient relations in delicate field of pain therapy are referred.
TANIKAWA T No Electrical stimulation for pain relief--spinal cord stimulation. Shinkei Geka 1983
Dec;11(12):1225-1236.
POZHIDAEVA LM, BOGDANOV NN, KACHAN AT Acupuncture procedure in the pain syndromes
following amputation of the extremities. [Article in Russian]. Ortop Travmatol Protez 1983 Feb;2:45-48.
PARRY CB, WITHRINGTON RH. Painful disorders of peripheral nerves. Postgrad Med J 1984
Dec;60(710):869-875
CARABELLI RA, KELLERMAN WC. Phantom limb pain: relief by application of TENS to contralateral
extremity. Arch Phys Med Rehabil 1985 Jul;66(7):466-467.
Three adult patients with below-knee amputation of various etiologies were treated at Norristown's Sacred
Heart Hospital and Rehabilitation Center in the fall of 1983. The patients ranged in age from 48 to 64 years and two
were men. All three had complaints of phantom limb pain originating from various anatomic sites of the amputated
extremity. In all three cases the phantom limb pain was severe and hampered prosthetic training. The patients were
treated solely by application of the TENS unit to the contralateral extremity at the sites where the phantom pain
originated on the amputated limb. All three patients responded to treatment and were able to continue their prosthetic
training. A six-month follow-up showed no pain recurrence of phantom limb pain in all three cases.
XUE CC Phenomenon of the route of sensation propagation and the cerebral cortex. [Article in Chinese].
Chung Hua Shen Ching Ching Shen Ko Tsa Chih 1985 Dec;18(6):357-360.
STAROBINETS MKH, VOLKOVA LD Treatment of phantom pain syndrome by acupuncture-like
cutaneous electric stimulation of the contralateral limb. [Article in Russian]. Ortop Travmatol Protez 1985
Aug;8:38-39.
XUE CC. Acupuncture induced phantom limb and meridian phenomenon in acquired and congenital
amputees. A suggestion of the use of acupuncture as a method for investigation of phantom limb. Chin Med J
(Engl) 1986 Mar;99(3):247-252
MAYO CLINIC, ROCHESTER, MN.. Chronic pain: use of TENS in the elderly. Thorsteinsson G. Department
of Physical Medicine and Rehabilitation, Geriatrics 1987 Dec;42(12):75-77
Transcutaneous electrical nerve stimulation (TENS) can be an important adjunct to the management of pain in
elderly patients. Chronic neuropathy and postfracture recovery are the leading indications for using the portable
stimulative device, although it has also been applied successfully in relieving low-back pain, postherpetic neuralgia,
myofascial pain, phantom-limb pain, and advanced, painful malignancies. However, TENS is rarely used alone in pain
relief, but instead should be part of a larger management program that may include other modalities.
IACONO RP, LINFORD J, SANDYK R. Pain management after lower extremity amputation. Neurosurgery
1987 Mar;20(3):496-500.
Phantom pain may occur in up to 85% of patients after limb amputation. Although the pathophysiology of
postamputation phantom pain is not well understood, it seems to be produced by a complex multifactorial interaction
between the peripheral, sympathetic, and central nervous systems. The theoretical aspects of this are reviewed.
Management of phantom limb pain may be both medical and surgical. Among the pharmacological agents proved
effective against phantom pain are beta-blockers, tricyclic antidepressants, and anticonvulsants. Surgical management
includes peripheral nerve stimulation, thermocontrolled coagulation of the spinal cord, spinal cord stimulation,
transcutaneous nerve stimulation, and stereotactic deep brain stimulation.
WOOD MR, HUNTER GA, MILLSTEIN SG. The value of revision surgery after initial amputation of an
upper or lower limb. Prosthet Orthot Int 1987 Apr;11(1):17-20.
The value of revision surgery when carried out more than six weeks after initial amputation of the upper or
lower limb was assessed. When performed for stump and/or phantom limb pain alone, only 33/95 (35%) obtained
satisfactory results after one revision; 25/95 (26%) of the patients required four or more surgical procedures without
relief of pain. However, when carried out for local specific pathology, the results of surgical revision were 100%
successful, even if the procedure had to be repeated once in 15% (28/189) of this group of patients. Transcutaneous
nerve stimulation appeared to offer no long lasting relief of pain following amputation surgery.
STOLIAROV VI, KEIER AN, TRISHKIN VA, SHCHERBINA KK, RAMON F. Medical rehabilitation of patients
after amputation of the leg in sarcoma. [Article in Russian]. Vestn Khir 1987 Jan;138(1):54-59.
An analysis of data of 348 patients with malignant tumors of soft tissues has shown that 128 of them had been
subjected to the amputation of extremities at different levels. The use of microsurgical techniques favours the
improvement of the method of amputation of lower extremities, in particular the transplantation of a calcaneoplantar flap
onto the stump end. In order to make the treatment of phantom limb pains more effective acupuncture should be
included into the complex of therapeutic measures in addition to traditional methods. Close contacts with
prostheses-makers can facilitate earlier prosthesis which can give positive effects on the following rehabilitation of such
patients.
FINSEN V, PERSEN L, LOVLIEN M, VESLEGAARD EK, SIMENSEN M, GASVANN AK, BENUM P
Transcutaneous electrical nerve stimulation after major amputation.. Trondheim University Hospital, Department of
Orthopaedic Surgery, Norway. J Bone Joint Surg [Br] 1988 Jan;70(1):109-112.
We studied the effect of transcutaneous electrical nerve stimulation (TENS) on stump healing and
postoperative and late phantom pain after major amputations of the lower limb. A total of 51 patients were randomised
to one of three postoperative treatment regimens: sham TENS and chlorpromazine medication, sham TENS only, and
active low frequency TENS. There were fewer re-amputations and more rapid stump healing among below-knee
amputees who had received active TENS. Sham TENS had a considerable placebo effect on pain. There were,
however, no significant differences in the analgesic requirements or reported prevalence of phantom pain between the
groups during the first four weeks. The prevalence of phantom pain after active TENS was significantly lower after four
months but not after more than one year.
HIRANO K, YAMASHIRO H, MAEDA N, TAKEUCHI T A case of long-standing phantom limb pain:
complete relief of pain. Masui 1988 Feb;37(2):222-225.
____. Dorsal column stimulation: its application in pain therapy. Devulder J. Dept. of Anesthesia, Univ.
Hospital, Ghent, Belgium. Clinical report about 45 patients treated with dorsal column stimulation. Acta Anaesthesiol
Belg 1989;40(2):121-122.
____. Acupuncture as therapy of traumatic affective disorders and of phantom limb pain syndrome.
Freed S. Heart Disease Research Foundation, Brooklyn, New York 11201. Acupunct Electrother Res
1989;14(2):121-129.
Functional isomorphism holds between four essential properties of acupuncture and of meditation, namely, 1)
alpha rhythm prominent in electro-encephalograms (EEG); 2) deep general relaxation; 3) high degree of
unresponsiveness to ordinarily painful stimuli; 4) participation of virtually the entire body. It is postulated, subject to
experimental test, that a "stillness" prevails during acupuncture similar to the quiet of meditation. The quiet of meditation
and by postulate, the "stillness" of acupuncture, provide high degree of unresponsiveness to aversive components of
conditioned stimuli which had habitually reactivated affective trauma. This marked unresponsiveness accounts for the
"stillness" and its EEG alpha rhythm. With its low noise level the "stillness" also provides the cerebral cortex better
resolved, more intense signals relative to background and more comprehensive, clear information. The cortex can then
call upon newly mobilizable, more precise regulation for removing imbalances throughout the body. The same factors
apply to the therapy by acupuncture of phantom limb pain syndrome if the pain impulses from the limb, while attached,
is the unconditioned stimulus of a reflex in which impulses from inner organs function as conditioned stimuli. Successful
therapy of the syndrome using laser-stimulated acupuncture points is discussed accordingly. Emphasized is the
desirability to maximize the "stillness," possibly by monitoring the course of therapy by displayed EEG.
KATZ J, FRANCE C, MELZACK R. An association between phantom limb sensations and stump skin
conductance during transcutaneous electrical nerve stimulation (TENS) applied to the contralateral leg: a case
study. Department of Psychology, McGill University, Montreal, Que, Canada. Pain 1989 Mar;36(3):367-377.
 This report describes a placebo-controlled study of transcutaneous electrical nerve stimulation (TENS) applied
to the contralateral lower leg and outer ears of an amputee with non-painful phantom sensations. The subject received
TENS or placebo stimulation on separate sessions in which baseline periods of no stimulation alternated with periods of
TENS (or placebo). Throughout the two sessions, continuous measures of stump skin conductance, surface skin
temperature and phantom intensity were obtained. The results showed that TENS applied to the contralateral leg was
significantly more effective than a placebo in decreasing the intensity of phantom sensations, whereas stimulation of the
outer ears led to a non-significant increase. The pattern of electrodermal activity on the TENS session was consistently
linear during baseline periods, indicating a progressive increase in sympathetic sudomotor activity. In contrast, during
periods of electrical stimulation the pattern of electrodermal activity was consistently curvilinear indicating an initial
decrease followed by an increase in sudomotor responses. Changes in stump skin conductance correlated significantly
with changes in phantom sensations both in TENS and placebo sessions suggesting a relationship between
sympathetic activity at the stump and paresthesias referred to the phantom. Two hypotheses are presented to account
for these findings.
KOVALENKO VV. Reflexotherapy in orthopedics, traumatology and prosthetics. [Article in Russian]. Ortop
Travmatol Protez 1990 Apr;4:66-68
GOLDMAN B Chronic pain and the search for alternative treatments. Can Med Assoc J 1991 Sep
1;145(5):508-509.
KUMAR K, NATH R, WYANT GM. DIVISION OF NEUROSURGERY, PLAINS HEALTH CENTRE,
UNIVERSITY OF SASKATCHEWAN, REGINA, CANADA.. Treatment of chronic pain by epidural spinal cord
stimulation: a 10-year experience. J Neurosurg 1991 Sep;75(3):402-407
Epidural spinal cord stimulation by means of chronically implanted electrodes was carried out on 121 patients
with pain of varied benign organic etiology. In 116 patients, the pain was confined to the back and lower extremities and,
of these, 56 exhibited the failed-back syndrome. Most patients were referred by a pain management service because of
failure of conventional pain treatment modalities. Electrodes were implanted at varying sites, dictated by the location of
pain. A total of 140 epidural implants were used: 76 unipolar, 46 Resume electrodes, 12 bipolar, and six quadripolar.
Patients were followed for periods ranging from 6 months to 10 years, with a mean follow-up period of 40 months.
Forty-eight patients (40%) were able to control their pain by neurostimulation alone. A further 14 patients (12%), in
addition to following a regular stimulation program, needed occasional analgesic supplements to achieve 50% or more
relief of the prestimulation pain. Pain secondary to arachnoiditis or perineural fibrosis following multiple intervertebral
disc operations, when predominantly confined to one lower extremity, seemed to respond favorably to this treatment.
Uniformly good results were also obtained in lower-extremity pain secondary to multiple sclerosis. Pain due to advanced
peripheral vascular disease of the lower limbs was well controlled, and amputation below the knee was delayed for up to
2 years in some patients. Pain due to cauda equina injury, paraplegic pain, phantom-limb pain, pure midline back pain
without radiculopathy, or pain due to primary bone or joint disease seemed to respond less well. Patients who
responded to preliminary transcutaneous electrical nerve stimulation generally did well with electrode implants. Notable
complications included wound infection, electrode displacement or fracturing, and fibrosis at the stimulating tip of the
electrode. Three patients in this series died due to unrelated causes. Epidural spinal cord stimulation has proven to be
an effective and safe means of controlling pain on a long-term basis in selected groups of patients. The mechanism of
action of stimulation-produced analgesia remains unclear; further studies to elucidate it might allow spinal cord
stimulation to be exploited more effectively in disorders that are currently refractory to this treatment modality.
KATZ J, MELZACK R.. Auricular transcutaneous electrical nerve stimulation (TENS) reduces phantom
limb pain. J Pain Symptom Manage 1991 Feb;6(2):73-83
The present paper evaluates the efficacy of low frequency, high intensity auricular transcutaneous electrical
nerve stimulation (TENS) for the relief of phantom limb pain. Auricular TENS was compared with a no-stimulation
placebo condition using a controlled crossover design in a group of amputees with (1) phantom limb pain (Group PLP),
(2) nonpainful phantom limb sensations (Group PLS), and (3) no phantom limb at all (Group No PL). Small, but
significant, reductions in the intensity of nonpainful phantom limb sensations were found for Group PLS during the
TENS but not the placebo condition. In addition, 10 min after receiving auricular TENS, Group PLP demonstrated a
modest, yet statistically significant decrease in pain as measured by the McGill Pain Questionnaire. Ratings of mood,
sleepiness, and anxiety remained virtually unchanged across test occasions and sessions, indicating that the decrease
in pain was not mediated by emotional factors. Further placebo-controlled trials of auricular TENS in patients with
phantom limb pain are recommended in order to evaluate the importance of electrical stimulation parameters such as
pulse width and rate, and to establish the duration of pain relief.
STANNARD CF. Phantom limb pain. Addenbrooke's Hospital, Cambridge. Br J Hosp Med 1993 Nov
14;50(10):583-584.
 Phantom limb pain is a common sequel to amputation, whether traumatic or surgical. Provision of a pain-free
interval before surgery is likely to reduce the incidence of the condition. The possible mechanisms of pain perception in
an absent body part and the reasons for the frequent failure of conventional therapy are discussed here.
FENOLLOSA P, PALLARES J, CERVERA J, PELEGRIN F, INIGO V, GINER M, FORNER V Chronic pain in
the spinal cord injured: statistical approach and pharmacological treatment.. Department of Aneasthesiology,
University Hospital, La Fe, Valencia, Spain. Paraplegia 1993 Nov;31(11):722-729.
We include in this article the results of a postal inquiry into chronic pain in SCI patients in Valencia (Spain), and
our experience with their management. A mailed questionnaire including lesion and chronic pain data was sent to all of
the 380 SCI patients who live in the region of Valencia. We received 202 answers, with 145 questionnaires being
accurately answered and these were analysed for this study. The results show that chronic pain (that is, lasting more
than 6 months) is very common (65.5%). The most frequent type was deafferentation pain (phantom pain), described as
burning or a painful numbness. Since 1988 we have been treating a sample of 33 patients suffering from resistant pain
according to the following therapies: 1 amitriptyline + clonazepam+NSAID (nonsteroidal antiinflammatory drugs); 2
amitriptyline + clonazepam + 5-OH-tryptophane + TENS (transcutaneous electrical nerve stimulation); 3 amitriptyline +
clonazepam + SCS (spinal cord stimulation); 4 morphine, by continuous intrathecal infusion. After almost 4 years using
these therapies we can affirm that the results regarding analgesia reached 80% in all cases, and that morphine used by
intrathecal route is very safe and useful in selected patients.
WESOLOWSKI JA, LEMA MJ. Phantom limb pain.. Department of Anesthesiology and Critical Care Medicine,
Roswell Park Cancer Institute, Buffalo, New York 14263-0001. Reg Anesth 1993 Mar;18(2):121-127
BROGGI G, SERVELLO D, DONES I, CARBONE G. ISTITUTO NAZIONALE NEUROLOGICO C. BESTA,
MILANO, ITALIA. Italian multicentric study on pain treatment with epidural spinal cord stimulation. Stereotact
Funct Neurosurg 1994;62(1-4):273-278.
A multicentric study on the treatment of nonmalignant chronic pain with epidural spinal cord stimulation (SCS)
has been carried out in 32 Italian centers devoted to pain therapy. Neurosurgical and anesthesiology units participated
in this retrospective study. 410 of the eligible patients were enrolled in the protocol: 48% were male, 52% female. All
patients underwent a screening test period (average 21 days) and 74% underwent the definitive implant. The diagnosis
was failed back surgery syndrome in 45%, reflex sympathetic dystrophy in 15%, phantom limb pain in 14%,
postherpetic neuralgia in 8%, peripheral nerve injury in 5%, others 13%. 84% received noninvasive unsuccessful
treatment (10 tensor acupuncture). All had previous pharmacological therapy which was not always discontinued when
SCS took place. Pain assessment had been done with the visual analog scale and verbal scale both subjectively and by
the physician and nurses. Neuropsychological profile with minimal mental test or MMPI was obtained in 68% of the
patients. These results were favorable (i.e. excellent or good; more than 50% reduction of pain) in 87% of the patients
at the 3-month follow-up, 75% at the 6-month follow-up, 69% at the 1-year follow-up, and 58% at the 2-year follow-up.
Complication rate was: dislocation of the electrocatheter 4%, technical problems 3%, infections of the system 2%. The
results will be discussed in correlation with the different etiologies of the nonmalignant chronic pain syndrome.
GNEZDILOV AV, SYROVEGIN AV, PLAKSIN SE, OVECHKIN AM, IVANOV AM, SUL'TIMOV SA. Evaluation
of the effectiveness of transcutaneous electroneuroanalgesia in phantom pain syndrome. [Article in Russian].
Anesteziol Reanimatol 1995 Mar;2:97-102.
Transcutaneous electroneurostimulation carried out in 24 patients with phantom pain syndrome completely
relieved pain in only 25% of patients. A possible cause of poor efficacy of this method is depletion of the endorphin
antinociceptive mechanisms. EEG findings indicated a possibility of objectively controlling the course of analgesia.
Specific EEG signs of phantom pain syndrome were distinguished: polymorphism of EEG fluctuations, high-frequency
rapid or slow electrical activity of the brain, and paroxysmal activity. Normalization of EEG, i.e. appearance of manifest
alpha-rhythm, reduction of the intensities of slow-wave and rapid activities with the relevant spectral changes, are signs
of a positive effect of the analgesic method used, as exemplified by transcutaneous electroneurostimulation.
SAGI-DOLEV AM, PRUTCHI D, NATHAN RH. Three-dimensional current density distribution under
surface stimulation electrodes. Biomedical Engineering Program, Ben-Gurion University of the Negev, Beer-Sheva,
Israel. Med Biol Eng Comput 1995 May;33(3 Spec No):403-408.
Overflow to non-target tissue during FNS can be reduced by controlling current density distribution under
surface stimulating electrodes. A method is introduced for the acquisition of 3-D current density distributions under
complex surface stimulating FNS electrode geometries. The method makes use of a phantom model in which a
conventional homogeneous model has been improved by adding a layer to simulate skin impedance properties, based
on specific FNS parameters. Signal acquisition and processing circuits have been developed to simulate the process by
which excitable tissue responds to external stimulation. In addition, a data analysis method has been introduced to allow
for the characterisation of stimulation current intensity, electrode geometry and pulse waveform required to achieve
target muscle activation, with minimal overflow and to avoid pain or burning. Measurements of integrated differential
voltage corresponding to current density distribution acquired under electrodes of various geometries are presented in
terms of 3-D attenuation coefficient maps as examples of the applicability of the method.
WARTAN SW, HAMANN W, WEDLEY JR, MCCOLL I Phantom pain and sensation among British veteran
amputees.. (UMDS-Anaesthetics), Guy's Hospital, London. Br J Anaesth 1997 Jun;78(6):652-659.
Using a mail-delivered questionnaire, we surveyed 590 veteran amputees concerning phantom pain, phantom
sensation and stump pain. They were selected randomly from a population of 2974 veterans with long-standing limb
amputation(s) using a computer random number generator. Eighty-nine percent responded and of these, 55% reported
phantom limb pain and 56% stump pain. There was a strong correlation between phantom pain and phantom sensation.
The intensity of phantom sensation was a significant predictor for the time course of phantom pain. In only 3% of
phantom limb pain sufferers did the condition become worse. One hundred and forty-nine amputees reporting phantom
pain discussed their pain with their family doctors; 49 were told that there was no treatment available. Transcutaneous
electric nerve stimulation, analgesics and non-steroidal anti-inflammatory drugs were satisfactory methods for
controlling phantom limb pain.

ACUPUNTURA "FALSA" SUPERA MEDICINA COMUM EM TESTE DA FOLHA DE S.PAULO

Daniel Cherkin & cols - Centro para Estudos da Saúde (Seattle – EUA) = Arquives of Internal Medicina –
Associação Médica Americana

O estudo com 638 voluntários com lombalgia, é um dos maiores ensaios já feitos para testar a acupuntura.
1º GRUPO – Tratamento convencional (remédios e fisioterapia) – “atendimento usual” – 39% de melhora
2º GRUPO – Acupuntura verdadeira – 60% de melhora
3º GRUPO – Acupuntura placebo (falsa) - picadas superficiais em pontos aleatórios do corpo.- 60% melhora
PERÍODO – 8 semanas.
EFEITO PLACEBO – Pílula de farinha sem nenhuma substância relevante
ACUPUNTURA PLACEBO - "agulha placebo", palito de dentes no tubo de suporte da agulha, com uma ligeira
pressão torcendo-o um pouco para simular uma agulha de acupuntura se agarrando à pele. No entanto, a aplicação
com o palito de dentes foi feita em pontos distantes das regiões tidas como corretas por acupunturistas profissionais.
CONCLUSÃO: Acupuntura falsa é igualmente eficaz, mas o tratamento convencional mostrou ser muito
ineficaz..
As primeiras pesquisas em acupuntura foram feitas para tentar evidenciar os postulados tradicionais (antigos),
como as pesquisas de Niboyet (década de 30) que demonstraram que muitos dos pontos clássicos apresentavam
diferença de potencial elétrico das regiões circunvizinhas = DETECTOR DE PONTOS, é uma diferença significante,
porém pequena, o que poderia gerar pequenas variações dependendo da pressão do operador podiam produzir
resultados errados. Um aperto maior levava a encontrar pontos em qualquer lugar do corpo - talvez antevendo o que
pesquisas mais modernas iriam definir - e ficávamos mais confusos do que sem ele. Seguindo o conselho dos colegas
mais velhos e verificando in loco a pouca precisão dos aparelhos, abandonei-o e preferi memorizar os pontos mais
importantes e procurar em um mapa aqueles mais difíceis, até que decorei a maior parte deles.

MACHIN. On the evaluation of the clinical effects of acupuncture. Revista Pain. 1983.
Dificuldades metodológicas da pesquisa em acupuntura
LEWITH. Can we assess the effects of acupuncture?. British Medical Journal. 1984.
Aprofundamento dos grandes desafios metodológicos.

Pesquisa empírica baseada em observações nem sempre controladas. Uma melhor estatística e muito
conhecimento médico gera benefícios para os próprios doentes (Dr. Cochrane) = Sistematização da pesquisa –
hierarquia de valor!
1. Opinião dos especialistas. Esta é a mais simples e a de menos valor.
2. Relato de caso. Um caso relatado de maneira organizada.
3. Estudo observacional. Sobre dado tratamento (20-1000 pessoas tratadas com certa droga sem controle).
4. Estudo caso-controle. Retrospectivos, avalia-se, por exemplo, se o hábito de fumar foi importante para provocar
certa doença, não fumantes são controle.
5. Estudos de coortes. Como um caso-controle prospectivo, isto é, avalia-se prospectivamente - para frente- uma
certa exposição, como o hábito de fumar e observa-se diferenças com os não fumantes.
6. Estudos clínicos randomizados. As pessoas são divididas em grupos, para tomar um remédio, por exemplo, para
certa doença, divididas aleatoriamente, por sorteio. São mascaradas, isto é, não sabem o que vão tomar, idealmente
os médicos também não sabem, só uma terceira pessoa detém a chave. (duplo-cego)
7. Metanálises. São avaliações teóricas feitas pela reunião de vários trabalhos clínicos randomizados de mesma
característica. Análise além da análise. Estudo feito com estudos já publicados, para somá-los e aumentar assim as
evidências. Banco de dados para avaliar os trabalhos publicados sobre o assunto – somar as boas metodologias
tomando um único trabalho com visão crítica, facilitando para os leitores (revisão de literatura com experimentação)
com uma espécie de resenha.
Considera-se que um bom tratamento deveria ter a avaliação 7, as outras só abririam caminho enquanto a
evidência 7 não é produzida. ESTUDO CLÍNICO RANDOMIZADO (Randomized Controlled Trial – RCT). SER
CONTROLADO – Ter grupo controle (recebendo tratamento padrão ou placebo)
Um controle correto é mascarado (cegar – inglês) - ele não deve saber se o medicamento que ele está
tomando é X ou Y (simples cego). Idealmente, o médico, que o está tratando e/ou avaliando, também não deveria
saber, apenas uma terceira pessoa o saberia (duplo-cego). Um placebo não de medicamento mas de procedimento é
chamado Sham (falso).