A Single Session of Acupuncture Therapy with Combination of Balance Method and Distal Point for the Treatment of Shoulder Calcific Tendinitis: A Case Report

Introduction

Movement of the shoulder joint can cause inflammation and pain in the tendons surrounding the joint and it may even be calcified within the degenerated tendon. The supraspinatus muscle tendon is very vulnerable because it can be squeezed by the greater humerus tubercle, the acromion, and the coracoacromial ligament. Tendinitis is a term often used to describe a variety of common and often occurring regional musculoskeletal conditions that are described primarily by disability and pain at the site involved. They may occur periarticularly or within certain soft tissue structures. Tendinitis is also used to describe inflammatory reactions in tendons.^1,2

In calcareous (or calcific) tendinitis (CT) of the shoulder, a calcified deposition (hydroxyapatite) is found in 1 or more tendons of the rotator cuff (usually the supraspinatus). These calcium crystals may sometimes break into the adjacent subacromial bursa, resulting in acute pain and soreness in the deltoid region. The bursae corresponding to the greater tuberosity and the subdeltoid (subacromial) bursa are the most common locations of calcified deposits. CT is one of the most frequently occurring causes of nontraumatic shoulder pain. CT is present in 10%–42% of chronic shoulder pain. Calcified deposits may also remain asymptomatic, occurring in 3% of painless shoulders. CT patients are typically between 30 and 60 years old, and women are more likely to be affected than men.^2,3

Inflammation induced by apatite crystal in the subcromial bursa, an enormous cell infiltration, consisting largely of polymorphonuclear cells and mononuclear phagocytic cells, occurs all over the pouch cavity and the membrane layer. In response to apatite stimulation, monocytes produce interleukin (IL)-1β and IL-6 and macrophages secrete IL-1β and IL-18 by activating NOD-, LRR- and pyrin domain-containing protein 3 inflammasome. Apatite crystals also trigger a signaling pathway that induces S100A8, which are identified as an endogenous activator Toll-like receptor 4, which in sequence cause reaction to cells to produce pro-IL-1β. In addition, macrophage may generate high levels of prostaglandin E2. Lastly, other synovial tissue cells may also participate in the production of proinflammatory factors after crystal stimulation. ³

The course of this disease can be divided into 3 separate clinical stages: acute, subacute, and chronic. The primary clinical manifestation is pain, which may or may not be associated with limitation of acute or progressive movements. Acute pain is usually associated with early illness. Calcium deposition can cause chronic pain with discomfort during activity. During its development, an acute inflammatory event may arise, resulting in loss of calcification. Throughout acute or hyperacute stage, the arm is normally held securely against the chest wall. Soreness is frequently spread over the perihumeral region. The patient may also experience night-time pain by lying on the affected side and with abduction of the arm. The impingement of the supraspinatus tendon is most apparent when the humerus is abducted and rotated internally. Other constitutional symptoms are scarce, but swelling may occasionally be apparent in hyperacute form, a fever and elevated sedimentation rate may develop in some patients.^2–4

For CT diagnosis and follow-up, typical radiographs in anterior–posterior position, with outlet and axillary views, are used because it allows localization and evaluation of texture and morphology of deposits. When shoulder radiographs show calcified deposits, the shadow seems “hazy” with thinning of the peripheral triggered by the force of inflammatory edema. Ultrasound (US) is a basic tool for diagnosing and treating of CT. The use of US has shifted from a simple diagnostic role into a significant therapeutic instrument, specifically for performing bursal lavage and tendon needling. The deposits can be divided into 3 types: (1) hyperechoic focus with well-defined shadow, (2) hyperechoic focus with a light shadow, and (3) hyperechoic focus without shadow. Magnetic resonance imaging can be used as an additional imaging tool but it is not essential.^2,4

Conservative treatment is always the first choice. This involves administration of nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, US guide needling, and extracorporeal shock wave therapy, ice, heat, electrical nerve stimulation, and acupuncture. Failure of nonoperative therapy is defined as continuation symptoms of CT in the shoulder after at least 6 months, containing at least 3 months of standard nonoperative care. If conservative treatment fails, then surgically removing the deposits is the last option. Commonly, acute phase needs NSAIDs for pain relief and a proper physiotherapy (passive ROM/range of motion exercise) to prevent stiff shoulders. Management of pain due to tendinitis can be improved by selecting and administering appropriate local injections. The effective therapy of local and intrasynovial injection needs consideration of the diagnosis, a precise location of the pathologic condition, and suitable injection method. To control pain, lidocaine and corticosteroid injection can be done independently or simultaneously. Corticosteroid injection therapy aims to relieve pain so that patients can return to their jobs and participate in a physical rehabilitation program. Nevertheless, injection treatment is best considered as a complement in managing pain in tendinitis syndromes. Injection must not be seen as a 1-time quick fix, but as a method of facilitating alternative modalities.^2,4

Therapeutic effects and mechanisms of local injection therapy for long-term analgesia cannot be clarified. Even though corticosteroids are recognized to decrease inflammation, it is not clear whether the anti-inflammatory effect is responsible for increasing the ROM and reducing pain that the patient typically feels. Pain in tendinitis may occur as a result of a mechanism other than inflammation, such as stimulating mechanoreceptor by substance P and chondroitin sulfate. It is recommended that corticosteroid injections never be repeated within the same location more than 1 time every 3 months. Corticosteroid side effects and local anesthetic are systemic, such as Cushing's syndrome, nausea, impaired diabetic control, and anaphylaxis, and local side effects such as recurrence of postinjection discomfort, depigmented skin, fat atrophy, hemorrhaging, bruising, steroid chalk calcification, nerve injury, rupture, and tendon atrophy, also infection of joint and soft tissue. ²

In 1979, acupuncture was proposed by World Health Organization as a clinically beneficial therapy for a variety of skeletal pain syndromes such as “frozen shoulder syndrome.” Acupuncture has broad acknowledgment in managing pain of musculoskeletal compared with other nonsurgical modalities and carries a near minimum risk of intervention. ⁵ This report describes a case of CT treated by acupuncture “balance method” where distal points are mostly used to treat pain in a specific body region.

Case Illustration

Case

A 56-year-old woman presented to the Medical Acupuncture Department of Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) with a complaint of 2 days unbearable pain in the right shoulder so that she cannot raise her arm. The pain spreads from the shoulder to her fingers and she has difficulty in combing her hair. She had no complaints about swelling or redness. History of shoulder pain has been felt since 2 years ago but never as painful as now. After consultation with another physician, she was prescribed analgesics, but the pain only slightly subsided and she never had any other course of treatment besides analgesics. Also, she had never complained about her left shoulder. The patient had a history of high blood pressure since 2 years ago and is currently taking her medication. There is no history of diabetes mellitus, allergies, or drinking blood thinners. No deformity was found during inspection of the shoulder. Physical examination revealed blood pressure of 145/86 mmHg with limited ROM in abduction (78.6°), lateral rotation (82.5°) of the right shoulder joint, and tenderness in acupoint Jianjing (GB21). A pain scale using numeric rating scale (NRS) was scored 5 (with diclofenac sodium 2 × 50 mg since 1 day ago). Radiologic findings revealed CT of the right shoulder (Fig. 1).

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FIG. 1.

Radiologic findings. Calcification on major perituberosity.

Methods

Therapy was carried out in reclined sitting position. First, to reduce patient's anxiety, acupuncture therapy is performed at the acupoint Baihui (GV20). Then at acupoint Tiaokou (ST38) in the direction to Chengshan (BL57) with 3 × 10 lifting thrusting stimulation. After that, a regimen of balance method acupuncture was prescribed. As the problematic channel of the shoulder was identified as the Gall Bladder channel, Sanjiao channel, and Large Intestine channel, distal points on the wrist and ankle contralateral were selected. Distal points on the wrist were selected around Neiguan (PC6) acupoint of Pericardium channel, around LU8 acupoint of Lung channel, around Lingdao (HT4) acupoint of Heart channel (Fig. 2A). In addition, distal points on the ankle were selected around Taixi (KI3) until KI7 acupoint of Kidney channel (Fig. 2B). Manual acupuncture was performed using a 0.20 × 15 mm stainless steel filiform disposable needle for GV20 and 0.25 × 40 mm stainless steel filiform disposable needle for other acupoints, with a total of 10 needles. The needle was inserted and stimulated only once until a sensation of de qi was achieved, and then retained for 45 minutes. After the session ended, NRS assessment score reduced from 5 to 2, ROM in abduction and lateral rotation of the right shoulder was improved, respectively, into 179.2° and 150.4° (Figs. 3 and 4). Follow-up was made 2 days later, ROM in abduction and lateral rotation became 168.9° and 147.8°, respectively, and the NRS assessment score was still 2. This patient signed a consent form for publication but without institutional review board involved.

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FIG. 2.

(A) Needling locations around PC6 acupoint of the Pericardium channel, around LU8 acupoint of Lung channel, around HT4 acupoint of Heart channel and (B) needling locations around KI3 until KI7 acupoint of the Kidney channel. HT4, Lingdao; KI3, Taixi; KI7, Fuliu; LU8, Jingqu; PC6, Neiguan.

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FIG. 3.

Improvement in ROM in abduction. (A) Before acupuncture treatment 78.6°. (B) After single acupuncture treatment 179.2°. ROM, range of motion.

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FIG. 4.

Improvement in ROM in lateral rotation of shoulder joint. (A) Before acupuncture treatment 82.5°. (B) After single acupuncture treatment 150.4°.

Discussion

Acupuncture has been widely used for the treatment of CT. In 1 study, Deganello et al. ⁶ noted that there were 78% of patients who experienced improvement in ROM before and after manual acupuncture with an improvement of >30° in both abduction and anterior lift of the arm, and >90% experienced painless and muscular strength improvement during abduction after 5 times weekly of acupuncture treatment. In another study by Papadopoulos et al., ⁵ after electro acupuncture 2 Hz every 4 days for 12 times in patients with CT, visual analogue scale (VAS) was decreased and measurement of active ROM improved. ⁵ Schröder et al. ⁷ used press tack needle on distal point from the shoulder (using reflex areas). This concept helps to avoid localized points in the painful area of the shoulder. This study shows that acupuncture with press tack needles on distal points may have far superior immediate effects than placebos. ⁷

The best way to explain the action of acupuncture for physiological effects and clinical responses is the stimulation of the underlying neuronal pathways of the peripheral and central nervous system. For analgesic effect of acupuncture, the theory of gate control and release of endogenous opioids has been elaborated. ⁸ By using distal points in shoulder pain treatment, the central area of pain plays an important role in acupuncture-induced analgesia. Acupuncture's immediate response improves separate activity patterns in the brain, especially in the limbic system, whereas in the prolonged stage, connectivity occurs between limbic/paralimbic region and brainstem nuclei with their neural activity focused on endogenous monoaminergic and opioidergic systems. ⁷ Another study by Bai ⁹ examines the difference in beneficial effect on shoulder pain between balance acupuncture and conventional acupuncture. Although the results in both interventions showed improvement in VAS, the improvement of the balance acupuncture group was greater than in the conventional acupuncture group. The instantaneous analgesia of balance acupuncture exceeds conventional acupuncture. ⁹

The balance method is an acupuncture method based on I Ching. This method is adapted to meridian theory, which has historically been used as an effective diagnostic tool for acupuncture therapy. Steps for diagnosis and balance method therapy are to (1) determine the diseased meridian, (2) determine the meridian to be treated based on 5 systems, and (3) determine the meridian point selected based on the second step, either by mirroring format or imaging format. Thus, the 5 balance method systems are (1) Chinese meridian name sharing, (2) Bie-Jing/branching meridians, (3) Biao-Li/interior–exterior pairs, (4) opposites on the Chinese clock, and (5) neighbors on the Chinese clock. ¹⁰

The use of distal points with balance method enables effective pain relief and improving ROM, as in this case. The mechanism of action of how distal points on a specific area of the body can produce pain relief and improve ROM is not fully understood. But study by Schröder et al. ⁷ could also explain the effectiveness of balance method in this case.

Conclusion

In this case, acupuncture using balance method and distal point effectively reduces pain and improves ROM of CT even after 2 days. Further research is required to ensure the reproducibility of this result and to explain the underlying mechanisms.