How Do You Treat Frozen Shoulder in Your Practice?

Abstract

I am a campanologist. This means that, as part of a team of ringers, I have to handle church bells weighing half a ton or more. So, when I developed a frozen shoulder I was worried that I would be unable to manage my bell, with possibly dangerous consequences. However, the action of large bell ringing involves anterior vertical movement of the arms, which I found I could do with ease. So, I was able to ring perfectly safely.¹ My restricted movements were reaching up behind my back (scrubbing-the-back movement) and reaching behind the neck (combing-the-hair movement). This is typical of frozen shoulder and provided a very good personal tutorial on which muscles are involved.

In general, for musculoskeletal problems, my first approach is to look for associated muscle trigger points, particularly if they coincide with traditional meridian acupuncture points. Travel and Simons stated that the primary trigger points found in frozen shoulder occur in the subscapularis muscle.² Unfortunately, this muscle lies on the anterior surface of the scapula and is thus difficult to access safely with an acupuncture needle. However, the initial severe pain of frozen shoulder is such that there is rapid recruitment of secondary trigger points in nearby muscles, and there is a suggestion that the intensifying pain and increasing restriction of movement may be due to these multiple additional trigger points. I search for these and attempt to deactivate them by manual needling to reduce muscle spasm and thus reduce pain.

Needle Placement

Often, the first accessible muscle to have trigger points is the deltoid, where LI 15 and TE 14 are usually tender to palpation. In addition, a variety of Small Intestine points (SI 9–SI 14) may be tender, mainly being associated with trigger points in the supraspinatus and infraspinatus muscles, with the most important points being SI 10 and SI 12. The trigger-point spread may even go down the arm to the biceps and triceps, and onto the chest (LU 1 and LU 2) in the pectoral muscles (but I take care not to needle there deeply). Invariably, shoulder pain leads to muscle pain and stiffness in the neck.³ Thus, I needle (superficially) GB 21 in the upper trapezius muscle and trigger points in the sternocleidomastoid muscle, including at GB 20.

I start with frequent manual acupuncture sessions to address specific trigger points in affected muscles. Then, as these are deactivated effectively and pain becomes controlled, I progress to gentle electroacupuncture at the Han frequencies of 2/100 Hz to acupuncture points across the shoulder. Patients report that this feels soothing and warm, indicating a restoration of the local blood flow interrupted by spasming muscles. Once pain has reduced to a level that allows physiotherapy, I advocate teaching self-help arm exercises to be used frequently at home to prevent further loss of mobility.

Three phases are described in the progression of frozen shoulder. The first, which may last about 6 months, is of progressive pain related to wider recruitment of muscle trigger points. The second, the so-called adhesive stage, lasts a further 6 months with increasingly restricted mobility. Finally, there is a slow period of recovery taking 1 year or more.⁴ This emphasizes the need for early acupuncture treatment to control the spread of trigger points.

Personal Case

My own journey through frozen shoulder was well-modified by early acupuncture treatment. My pain was eliminated effectively at rest and during normal activity, but the limitation of movement did not improve, although it did not progress any further and lasted only 6 months in total, after which my movement had returned completely to normal. This is the same pattern of benefit, in terms of pain but not improved mobility, that I have seen in those of my patients whom I have been able to treat early, before progression has taken place.

Summary

The more-standard/biomedical name for frozen shoulder is adhesive capsulitis. The name reflects the shoulder capsule changes of fibrosis, and the stickiness and thickening of the synovial membrane. Thus, not surprisingly, joint mobility has proven to be less responsive to trigger-point acupuncture than the pain related to muscle spasm. Nonetheless, early acupuncture treatment can halt further restriction of movement and enable a more-rapid resolution.

Address correspondence to:

Simon Hayhoe, MSc, MBBS, MRCA, DA

Pain Management Department

University Hospital

Turner Road

Colchester CO4 5JL

United Kingdom

E-mail: simonhayhoe@doctors.org.uk

Frozen shoulder is a chronic pain condition in the shoulder joint that lasts more than 3 months. This condition can be caused by inflammation of the glenohumeral joint capsule followed by progressive stiffness causing limited range of motion (ROM) of the joint.¹ The prevalence of frozen shoulder ranges from 2% to 5% and increases to 10%–38% in patients with diabetes.² The etiology of frozen shoulder is not known for certain but, based on epidemiologic studies, it has been shown that frozen shoulder is associated with diabetes mellitus, stroke, thyroid disorders, shoulder injuries, Parkinson's disease, and cancer.¹

From the latest systematic review in 2020 about the effectiveness of acupuncture in frozen-shoulder therapy,³ it was concluded that acupuncture is safe and effective for reducing pain intensity, improving shoulder-joint function, and restoring the ROM of the joint, although the level of evidence is still very low. The review showed that the most widely used acupoints for treating frozen shoulder are LI 15 and TE 14. This is in accordance with the local acupoints in the shoulder joint.

Diagnostic Criteria

Diagnosis of frozen shoulder is based on the patient's history and a physical examination. The presence of anterior shoulder pain, which is usually unilateral, is accompanied by limited ROM of the joint, either actively or passively. Movement is limited to shoulder-joint exorotation and arm abduction. In general, the severity of the condition depends on the stage of frozen shoulder. There are 3 stages of frozen shoulder, namely (1) the freezing phase (2–9 months); (3) the frozen phase (4–12 months); and (3) the thawing phase (12–42 months). Functionally, frozen shoulder usually affects the patient's daily activities due to limited movement of the shoulder joint during activities. There are no specific laboratory or imaging tests to make a definitive diagnosis of frozen shoulder.^1,2

Case Illustration

A 46-year-old male complained of pain in the right shoulder lasting for 3 months. There was no history of previous trauma. This patient had a daily habit carrying a heavy backpack while working. He complained of pain on a level of 5–6 when raising his hand. On physical examination, there was tenderness in the deltoid muscle and triceps muscle. In forward flexion, the angle of motion was less than 45°, the same degree as the angle of abduction. On endorotation, he was able to reach up to the 3rd lumbar level.

This patient received therapy using thread-embedment acupuncture (TEA). The material used was a 26 G, 90-mm long polydioxanone (PDO) mono thread. The PDO was inserted at the TE 10 point leading to the TE 12 point at an angle of 45°. After penetrating the skin, the insertion angle was changed to horizontal (10°–20°) and then the entire needle body went inside. It was necessary to ensure that the tip of the needle was pointing toward the acromion, then to pull the needle out while holding the thread support against his skin.

Evaluation of the patient on a pain scale and ROM was carried out right after the procedure was completed and 1 month after TEA. Right after the procedure, this patient's pain level decreased to 4, the angle of forward flexion changed to 60°, the angle of abduction changed to 80°, and the internal rotation increased to the level of vertebrae T-12. On evaluation after 1 month, the patient's pain level decreased to 1–2, and there were no post-treatment complications.

Summary

The same technique can be performed by using the penetrating needling from the TE 10 point to the TE 12 point. Penetrating needling is a technique that reaches 2 or more acupoints using one needle.⁴ The puncturing is performed when a patient is in the prone position. A 125 × 0.3–mm needle is inserted at an angle of 45°until it penetrates the skin, then the insertion angle is made horizontal, slowly, while being inserted subcutaneously into the TE 12 point. The needle is palpated with the left hand to ensure that the depth and direction of the needle are correct. The stimulation method used is lifting and thrusting movements with a frequency of 100 times per minute, and the needle is retained for 30 minutes. This stimulation is repeated every 10 minutes. Acupuncture therapy is performed 2 times per week for 6 weeks (for a total of 12 sessions).

Address correspondence to:

Wahyuningsih Djaali, MD

Universitas Negeri Jakarta, Jakarta, Indonesia.

Jl. Rawamangun Muka

East Jakarta, Jakarta 13220

Indonesia

E-mail: inchy86@yahoo.com

And Aswadi Ibrahim, MD¹ Bazzar Ari Mighra, MD² and Yoshua Viventius, MD³

¹Universitas Hasanuddin, Makassar

²Universitas Negeri, Jakarta

³Universitas Indonesia/Rumah Sakit Umum Pusat Nasional Dr. Universitas Indonesia/RSUPN Dr. Cipto Mangunkusumo, Jakarta Indonesia

For the last 20 years, most of my patients have had musculoskeletal issues, and ∼25%–30% of these patients had shoulder problems. Over the years, I tried different approaches, and the following method has worked particularly well for patients with shoulder conditions, such as frozen shoulder, that involved stiffness and soft-tissue adhesions, with the main symptoms of restricted movement more than inflammation.

The most-effective treatments typically did not involve using only classical acupuncture points, but, rather, either Ah-Shi points¹ or a combination of classical and Ah-Shi points.² The final decision on specific point selections and individual points' exact locations, however, depends almost exclusively on a palpation technique. In fact, both point selection and location can vary significantly from patient to patient, and even during the treatment course of the same patient, if the palpation findings justify the variations in treatments.

The palpation technique that I have been relying on looks like light-pressure on smaller and larger areas of the soft tissues of the affected shoulder, neck, and upper arm.³ Using light pinches, as opposed to applying pressure vertically to the skin surface—the way it is usually done—enables me to identify the exact locations of soft-tissue adhesions and stiffness. Variations in depth and angle of the pressure enabled me to pinpoint the most effective points for each individual patient in each individual session.

Curiously, acupressure alone can often resolve a case of frozen shoulder in 3–7 sessions, but acupuncture causes significantly less pain, particularly when there is much inflammation in the shoulder. The active points become evident when light pressure is applied, using large pinches, which causes the patient disproportionately intense pain. A slight change in the angle or depth of the same light pressure, however, makes the intensity of pain lesser or greater.

The same exact pressure angle needs to be reproduced when an acupuncture needle is inserted. The number of needles depends on the size of the area of stiffness, and the depth of insertion is defined by the depth of palpation, but the points are located on the fascia and muscle surface, so the insertion is typically relatively superficial. In addition, due to the high sensitivity of the active points, achieving De Qi is not necessary—that stimulation would cause too much pain. After identifying the precise depth and angle of the pain-causing adhesion and/or stiffness, I usually insert between 4 and 10, 0.25-mm thick, 1" needles, or 2" needles if the 1" needles do not reach to the active points around the painful stiffness area. Insertion of fewer needles directly into the sorest points often causes the patient more pain.

Insertion of several needles into the edges of the stiff area helps dissolve the stiffness in 5–10 treatment sessions. Treatment progress can be monitored using the same palpation that was used to diagnose the condition; this should confirm that the area of stiffness is becoming smaller after each treatment session.

While additional points, herbs, or other modalities can—and sometimes should—be used for addressing other, either underlying or parallel, issues these additions rarely affect the outcome of the frozen-shoulder treatment, although, specific circumstances may require the additional modalities.

Address correspondence to:

Vladislav Korostyshevskiy, LAc, MS, MEd

2678 Ocean Avenue, Apt. 2E

Brooklyn, NY 11229

E-mail: vk546@nyu.edu

The causes of adhesive capsulitis (frozen shoulder) are not fully understood. It is commonly described as a condition that may resolve itself, naturally over time (up to 3 years). Throughout 30 years in my clinical practice, patients have presented with chronic frozen shoulder after failing to resolve it, despite attempts to do so via numerous conventional Western medical treatment approaches. Previous treatment typically included physical therapy modalities for stretching and strength, as well as anti-inflammatory drugs, pain medications, and steroid injections. The focus of conventional treatments is pain modulation and increasing range of motion, associated with three distinct stages (freezing, frozen, thawing). Patients typically have had comprehensive prior medical evaluation, including range of motion examinations, X-ray, and MRI.

The purpose of our auricular acupuncture-centered treatment is to trigger natural auto-resolution of frozen shoulder (typically in 1–3 months) without the need for stretches, exercises, or other active therapeutic activities. Although diagnostic imaging is not considered necessary for arriving at the diagnosis of adhesive capsulitis, it is best to first rule out any structural problems. Pain and restricted ranges of shoulder motion are not sufficient evidence. If the patient does not have any complicating structural damage or deficits, treatment can ensue. It is accomplished via a combination of wellness-promoting supportive techniques. Three-phase auricular therapy is primary. A sufferer of adhesive capsulitis commonly presents with electrically active points within all three phase zones (acute, chronic, physical damage/degenerative).

There are no generic shoulder points as per point-based ear acupuncture charts.

Treatment will be different for each patient and tailored based upon findings. Shoulder zones (P. Nogier/N. Soliman)¹ are scanned using an acupuncture point detector. In a case example, the patient would initially receive treatment twice per week for 4 weeks. Active points detected are treated with electrical stimulation for a few minutes with frequencies appropriate to each zone (Fig. 1). In some cases, semipermanent, size #3 SEIRIN^® Spinex^™ intradermal needles (Lhasa OMS, Weymouth, MA) are inserted and covered with protective tape. Adherence is fortified by applying Mastisol^® medical liquid adhesive (Eloquest^® Healthcare, Detroit, MI). This enables ongoing stimulation for days to several weeks.

FIG. 1.

Adhesive capsulitis (frozen shoulder). Auricular Therapy Zones. ©D. Liebell, 2022.

Additionally, cervical spine auricular projections are evaluated and treated to address the spinal nerve supply component of AC.¹ Supporting proper nerve transmission from the cervical spine to the peripheral nerves via chiropractic adjustments is complementary and effective. A handheld piezoelectric stimulator is used several times on tender spots (Ashi acupuncture points) palpated throughout the musculature of the patient's shoulders, upper thoracic and lower cervical spine. Low Level Laser Therapy (3LT® Erchonia Medical Corp. Melbourne, FL) is administered to these regions simultaneously, at 45 Hz (bone), 42 Hz (lymphatic), 8 Hz, and 750 Hz (frequencies found to be beneficial for shoulder through clinical experience) for 3 minutes (<5mV, 635 nm wavelength).

Natural resolution of frozen shoulder has been consistently successful using this combination of methods. At least some level of improvement, including increased range of motion and decreased pain is expected within the initial 4 weeks of treatment. Re-evaluation is performed, typically resulting in decreasing treatment frequency to once per week for another 4 weeks. Complete resolution may take a total of ∼3 months, however, the cases typically seen had previously not improved at all for considerable time, despite various interventions.

DISCLOSURE STATEMENT

No competing financial interests exist

Address correspondence to:

Donald K. Liebell, DC, BCAO, BA

The Liebell Clinic—Chronic Pain & Wellness Solutions

477 Viking Drive Virginia Beach, VA 23452

E-mail: necksecret@gmail.com

Adhesive capsulitis is a complex and multifaceted condition. There are many factors which determine how to approach the condition when creating a viable treatment plan. This is a brief overview of factors at play followed by a case study.

History

Establish the length of time and nature of the condition. Is it mechanical or related to an existing condition (i.e., diabetes, chronic systemic condition)?

Assessment

Determine what is the baseline range of movement. Is it possible that it is not frozen shoulder, but another condition (i.e., rotator cuff tear, motor inhibition etc.)?

What measurable assessment protocol are you using to establish a correct diagnosis?

Treatment

With chronic systemic patients, you will NOT needle deeper than the skin. This will activate the sympathetic nervous system via the muscle spindles.^1,2

In mechanical causes using motor points and muscle-based needling techniques, use perfusion-based techniques in both mechanical and chronic systemic cases by normalizing the autonomic nervous system to maximize blood flow to injured tissues.²

CASE STUDY

History

A 62-year-old man with a history of type II diabetes presented with an endomorphic body type and stood at 6 feet tall and 260 pounds. The patient was unable to move his right shoulder, which was limited in flexion, abduction, and extension/internal rotation (quantified in degrees below).

The problem began 10 months ago after a slip and fall onto ice while shoveling snow from his driveway. X-rays were unremarkable. The shoulder began to stiffen 5 days after the fall. He tried conventional measures (NSAIDs, ice/heat, and physical therapy which consisted of ultrasound and capsular stretching).

Due to his chronic systemic condition (diabetes), deep needling into muscle was avoided. This is because such a condition carries with it a high sympathetic tone.^3,4 Needling deep into muscles stimulates sympathetic nerve fibers around the muscle spindles, which triggers a noxious response and increases the pain experience, often leading to flare-ups or regression in pain relief and reduced movement.^5,6

Assessment

Range of motion (ROM)

Shoulder flexion 20°

Shoulder abduction 15°

Extension with internal rotation (hand behind back): hand only able to reach top of back pocket. This is classified as a positive modified Apley's Scratch Test.⁷

○ both hands are very cold on palpation examination.

Manual muscle testing

Serratus anterior and rotator cuff muscles unable to be challenged with motor muscle testing due to pain.

Traditional CM diagnosis

As is consistent with systemic disease, deficiency patterns accompany it. This presentation reflected as local qi/blood stagnation.⁸ With such a presentation, any chronic systemic problem needs to be treated conservatively, making certain to not overtreat or mistreat any condition with an underlying deficiency pattern.^1,2 Overstimulation could trigger a flare-up in patients with these characteristics.

Treatment

Due to the CM diagnosis, coupled with the conventional orthopedic presentation, and the addition of the existing of chronic systemic illness (diabetes), needling needed to be focused on decreasing sympathetic tone and improving peripheral circulation to the extremities.

Perfusion treatment

Insert needles at HJJ points corresponding with spinal levels T1-T5. Clip wires to needles at T1 and T5 and stimulate with electricity at 2 Hz for 15 minutes. This neuromodulates the autonomic nervous system to improve blood flow to the head, neck, and upper extremities.^9,10

Auricular/distal

Bilateral Point Zero points in both ears. Point Zero has a direct relationship to the vagus nerve which instantly balances the autonomic nervous system by stimulating the parasympathic control.¹¹

Bilateral LR3 insertion points. Research demonstrates that stimulation of LR3 improves blood flow through the brachial artery of the arm. This increased perfusion will stimulate tissue repair.

High frequency electroacupuncture to sclerotomal tissues.⁹

Using a 2NT (two-needle technique) into the coracohumeral ligament, stimulate it with 100 Hz of electricity. Insert both needles into JianLiao (TE 14). Clip the red and black wires to the needles and set to 100 Hz for 15 minutes.

Results

After 8 treatments over a period of 4 weeks the patient responded as follows:

ROM shoulder flexion 90°

ROM shoulder abduction 65°

Extension with internal rotation (hand behind back): patient was able to reach level L3 spinous process.

Address correspondence to:

Anthony Lombardi, DC

Hamilton Back Clinic

Hamilton, Ontario L8W 3P1

Canada

E-mail: exstore@usa.com

References

Grandsire Doubles at Narborough. Online video at: https://tinyurl.com/2p9fbvnc Accessed April 9, 2022.

Travell

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. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins; 1983.

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K-V

. Frozen Shoulder. Updated September 1, 2021. Treasure Island, FL: StatPearls Publishing; 2022. Online document at: www.ncbi.nlm.nih.gov/books/NBK482162/#article-21982.s3 Accessed February 28, 2022.

Carmignano

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Frozen Shoulder: Symptoms, Causes, Diagnosis, and Treatment. IntechOpen; 2022. Online document at: www.semanticscholar.org/paper/Frozen-Shoulder%3A-Symptoms%2C-Causes%2C-Diagnosis%2C-and-Carmignano/d257c4b41e4414b16ad3320312d7249d84247bca Accessed February 28, 2022.

Ben-Arie

, Kao

P-Y

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Yan

. Diagrams of Acupuncture Manipulations [Chinese–English ed]. Shanghi: Shanghai Scientific and Technical Publishers; 2003.

Nugent-Head

. Ashi points in clinical practice. J Chin Med, 2013; 101:5–12.

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Fukushima

. Meridian Therapy: A Hands-on Text on Traditional Japanese Hari Based on Pulse Diagnosis, 3rd ed. Toyo Hari Medical Association: Tokyo; 1999:166–169.

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Shudo

, Brown S (transl). Finding Effective Acupuncture Points, 1st ed. Seattle: Eastland Press; 2003.

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Soliman

. Soliman's Auricular Therapy Textbook: New Localizations and Evidence Based Therapeutic Approaches. Bloomington, IL: Authorhouse; 2008.

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Wang

, Huang

, Chiou

, et al. Therapeutic effect of superficial acupuncture in treating myofascial pain of the upper trapezius muscle: a randomized controlled trial. Evid Based Complement Alternat Med. 2018; 9125746.

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Sandberg

, Larsson

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, et al. Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work. Eur J Pain. 2005; 9:497–510.

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Burton

, Falzalbhoy

, Macefield

Sympathetic responses to noxious stimulation of muscle and skin. Front Neurol. 2016; https://doi.org/10.3389/fneur.2016.00109.

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Hallman

, Lyskov

. Autonomic Regulation in Musculoskeletal Pain. In: Pain in Perspective, S. Ghosh (ed.) London, UK: IntechOpen.

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Hsu

H-C

, Hsieh

C-L

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K-T

, et al. Electroacupuncture reduces fibromyalgia pain by downregulating the TRPV1–pERK signalling pathway in the mouse brain. Acupunct Med. 2020; 28:101–108.

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Song-Yi

, Seorim

, Hyangsook

, Soyeon

, et al. Changes of local blood flow in response to acupuncture stimulation: a systematic review. Evid Based Complement Alternat Med. 2016:1–11.

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Yang

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Zhang

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Dosch

. Manual of Neural Therapy According to Huneke. Chapter 2. 1st English ed. 2007

23.

Kaniusis et al. Current directions in the auricular vagus nerve stimulation i – a physiological perspective. Front Neurosci. 2019; 13:854–872.

How Do You Treat Frozen Shoulder in Your Practice?

Abstract

Needle Placement

Personal Case

Summary

Diagnostic Criteria

Case Illustration

Summary

DISCLOSURE STATEMENT

History

Assessment

Treatment

CASE STUDY

History

Assessment

Traditional CM diagnosis

Treatment

Perfusion treatment

Auricular/distal

High frequency electroacupuncture to sclerotomal tissues. 9

Results

References

High frequency electroacupuncture to sclerotomal tissues.⁹