Acupuncture for Shoulder Pain

/, Research/Acupuncture for Shoulder Pain

Acupuncture for Shoulder Pain

This article explores different types of shoulder injuries and the benefits of acupuncture as a treatment option.

Contents (click to jump to section)

Shoulder Pain

Shoulder Impingement Syndrome

Frozen Shoulder

Acupuncture Treatment

Research

Click here to find out about acupuncture for workcover and ctp claims…

Shoulder Pain

Shoulder pain is very common and can be defined as pain occurring in and around the articular surfaces of the shoulder girdle, including the glenohumeral (socket), acromioclavicular (AC) and sternoclavicular (SC) joints (1). Common causes of shoulder pain include adhesive capsulitis (frozen shoulder), rotator cuff strain or tear, impingement syndrome, subacromial bursitis, glenohumeral osteoarthritis and biceps tendonitis (2).

Disorders of the shoulder muscles and tendons (rotator cuff) are considered to be one of the most common causes of pain and they have a major impact on quality of life (3). These conditions become more common with increased age or certain work-related and sporting activities, and are characterised by pain, limited strength and movement, and loss of shoulder function (4).

Standard care

Standard treatment options for shoulder pain include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular and subacromial injections of glucocorticosteroids, oral steroids, physiotherapy, manipulation under anesthesia, and hydrodilatation with surgery being a last resort (5).

Acupuncture

The recent publication of The Acupuncture Evidence Project shows that there is moderate evidence to support the effectiveness of acupuncture in the treatment of shoulder pain and shoulder impingement syndrome (early stage with exercise) (6).

Shoulder Impingement Syndrome (Subacromial impingement syndrome)

Patients with this syndrome may experience pain in the deltoid muscle region, particularly during elevation of the arm (7). Pain can be due to compression of tendons from bony structures within the shoulder joint or degenerative changes in the rotator cuff (8). Other causes can be rotator cuff tendinosis or subacromial bursitis due to inflammation (9).

This is a common condition of the shoulder that is usually seen in labourers or people working in jobs with repetitive overhead activity, and in athletes (swimming, throwing sports, tennis, volleyball) (10). A sudden onset of sharp pain in the shoulder with a tearing sensation is indicative of a rotator cuff tear while a gradual increase in shoulder pain with overhead activities may indicate an impingement problem (11).

Standard Care

In the acute phase, standard treatment options include physical therapy, subacromial injection of corticosteroids or local anaesthetic, high-intensity laser therapy or surgical intervention, while rehabilitation and maintenance consist of physical therapy (12). Medications include non-steroidal anti-inflammatory drugs, celebrex, tramadol and paracetamol (13).

Frozen Shoulder

Also known as adhesive capsulitis, frozen shoulder is a common condition characterised by pain and stiffness in the shoulder with severe loss of range and motion (14). It can occur either as the primary condition or as secondary to an underlying condition (15).

There are 3 stages to frozen shoulder:

1) painful or freezing phase lasting 10 – 36 weeks (16), characterised by progressive pain and decreased range of motion (17)
2) still or frozen phase lasting 4 – 12 months (18),  characterised by decreased pain but increased restriction of movement (19) and
3) recovery or thawing phase lasting 5 – 26 months or more (20),  characterized by a gradual increase in the range of motion (21).

Although the frozen shoulder may “thaw out”, full range of motion may not always return (22). The condition is considered to be self-limiting meaning that it can last between 18 – 24 months, however while most patients recover completely, many others can be left with long term pain and residual motion restriction (23).

Standard Care

Standard treatment options for frozen shoulder include nonsteroidal anti-inflammatory medications, oral or injectable corticosteroids may also be prescribed (24). Physical therapy including gentle range of motion exercises, ultrasound, massage, kinesiological taping, electrical stimulation, or laser stimulation (25).

Intra-articular corticosteroid injections may be considered concurrent with physical therapy to reduce pain and improve range of movement (26). Surgical options are capsular distension through hydrodilation, joint manipulation under anesthesia and capsular release (27).

Acupuncture Treatment

Acupuncture for Shoulder Pain
Image 1.

Studies have shown that acupuncture can provide pain relief, improve range of motion and speed up recovery time. Shoulder pain is one of the conditions listed in the Acupuncture Evidence Project for which there is moderate evidence supporting the use of acupuncture as an effective treatment (28). Electroacupuncture is often used in the treatment of injuries as it has been found to release powerful pain relieving substances within the body (references and article here).

What to expect

Following the first treatment it is possible to feel a either marked improvement, no change, or a temporary exacerbation of the pain. While an improvement in range of motion and reduction of pain is a positive sign, it does not necessarily indicate instantaneous recovery. It may however indicate that the body is responding well and that a follow up treatment soon after is advisable to maintain this momentum. A common mistake made by patients is believing they are fully recovered after just one treatment and going back to normal duties which can further set back recovery time or even worsen the injury.

Similarly, if the state of the condition does not change or temporarily worsens, this does not necessarily indicate a negative response. Depending on how the long the injury has been present may affect the body’s response time to treatment and it may take more than one session to gain noticeable relief. On occasion the body can react to treatment in seemingly adverse ways such as increased pain, but this is usually very short term and commonly followed by an improvement of the condition.

Course of treatments

As is the case with most musculoskeletal conditions, 2 weekly treatments for at least several weeks are generally advised in the initial stages to gain momentum and see effective results before spacing the treatments out to once per week/ per fortnight/ per month. While it is not uncommon for positive results to be seen immediately after a single treatment or in the following hours or days, the effects of acupuncture can also be cumulative so a treatment plan consisting of multiple treatments may be advised in order to see more effective results.

There are a wide range of factors that determine the amount of time and treatments required for any patient’s condition. Duration and severity of the condition play a big part in determining the length and extent of your treatment plan. If the condition is less severe and has only been present for a short amount of time, then a greater response with faster recovery time is more likely. With chronic and more severe conditions, weeks or perhaps even months of consistent, yet less frequent treatments may be required in order to restore full function or for the condition to be manageable.

Other factors that play a role in response to treatment are age and and general health of the patient. What you do after your treatment also has an effect on how well you respond. The more you can do post-treatment to complement the acupuncture, the better your results will be. This may include performing assigned stretches, or using prescribed herbs or liniment to support the acupuncture, or not exerting yourself in the time following the session which may undo the treatment.

Acupuncture research for shoulder conditions – click to expand

Patients diagnosed with adhesive capsulitis, rotator cuff syndromes, rotator cuff tear, osteoarthritis, biceps tendonitis, or subacromial bursitis were treated with either traditional Chinese acupuncture, acupuncture based on a standard shoulder treatment protocol, or sham acupuncture that uses a retractable, non-penetrating needle device that gives the patient a pricking sensation (29). Patients in each group received treatments twice per week for 6 weeks and pain and disability scores were taken at the start and end of treatment program (30).

Results

Following the six weeks of treatment, patients in both the traditional and standard protocol acupuncture groups showed a clinically significant improvement from baseline with both pain and disability compared to the sham group (30). While patients in the sham group showed some improvement in total, the results were not clinically significant (32).

425 patients were divided into two groups and treated with either acupuncture in conjunction with physiotherapy in the ‘experimental group’ or mock TENS (transcutaneous electronic nerve stimulation) and physiotherapy in the control group (33). The acupuncture consisted of a single point – ST38 – that is indicated for the treatment of shoulder pain (34).

These patients presented chronic symptoms of unilateral subacromial syndrome (rotator cuff tendonitis or subacromial bursitis, in some cases associated with capsulitis), with a case history duration equal to or exceeding 3 months (35). Both treatments were provided once a week for three weeks, while all patients also received 15 sessions of physiotherapy over this time (Vas 888). Patients were allowed to take analgesic or NSAID medication on request (36).

Results

The Constant–Murley Score was used with a maximum of 100 points indicating a shoulder with mobility completely free from pain and with normal functioning (37). At one week following the end of treatment, the experimental group had improved by 16.6 points while the control group improved by 10.6 points (38). Mean values for intensity of daytime and nighttime pain, previous consumption of anti-inflammatory medication and days off for sick leave were all improved in the experimental group compared to the control group overall (39).

This review examines the results of 39 research papers for a varying range of treatments, including three papers about acupuncture, for the treatment of frozen shoulder.

In summary, the review found that pain was better controlled by acupuncture than physical therapy, and that electroacupuncture is effective for both short and long term pain relief (40). While physical therapy provided greater improvement than acupuncture for range of motion, combined acupuncture and physical therapy provides better improvement than either acupuncture or physical therapy alone. (41). Overall function was improved from acupuncture and physical therapy combined than physical exercise alone (42).

52 sportsmen with rotator cuff tendonitis were treated for 4 weeks comparing acupuncture with a placebo control (43). The real acupuncture treatment was shown to be more effective than placebo with an improvement of 19.2 Constant-Murley-score points, where the control group improved by 8.37 points (44).

91 patients were randomised into two groups to receive either acupuncture combined with home exercises or corticosteroid injection (45). Patients in the corticosteroid group were advised to refrain from heavy arm activities for two weeks following the injection (46). They were allowed to return to usual duties after this while voiding obviously provoking movements, and they were allowed a second injection if the effects of the first were doubtful (47). Patients in the acupuncture group received treatments twice per week for five weeks in conjunction with a two-step exercise program aimed at restoring movement and strengthening rotator cuff with low-intensity movements (48).

Following the completion of the trial it was found that no treatment was superior as both showed a significant positive change in pain and shoulder function (49). This is an indication for the effectiveness of acupuncture and also provides a more natural alternative treatment for those patients wishing to avoid corticosteroids.

  1. Lathia, A, Jung, S & Chen, L 2009, ‘Efficacy of Acupuncture as a Treatment for Chronic Shoulder Pain’, THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE, Vol. 15 No. 6, pp.613 – 618, viewed 7 June 2017, www.ebsco.com, p. 613
  2. Ibid
  3. Fu, Q, Shi, G, Li, Q, He, T, Liu, B, Sun, S, Wang, J, Tan, C, Yang, B & Liu, C 2014, ‘Acupuncture at local and distal points for chronic shoulder pain: study protocol for a randomized controlled trial’, BioMed Central, Vol. 15, No. 130, viewed 7 June 2017, www.ebsco.com, p. 3
  4. Vas, J, Ortega, C, Olmo, V, Perez-Fernandez, F, Hernandez, L, Medina, I, Seminario, J, Herrera, A, Luna, F, Perea-Milla, E, Mendez, C, Madrazo, F, Jimenez, C, Ruiz, M & Aguilar, I 2008, ‘Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial’, Rheumatology, Vol. 47, pp. 887–893, viewed June 7 2017, www.ebsco.com, p. 887
  5. Lathia et al. 2009, loc.cit.
  6. McDonald, J & Janz, S 2017, ‘The Acupuncture Evidence Project: Plain English Summary’, AACMA Website, viewed 21 April 2017, http://acupuncture.org.au/OURSERVICES/Publications/AcupunctureEvidenceProject.aspx, p. 2
  7. Johansson, K, Adolfsson, L & Foldevi, M 2005, ‘Effects of Acupuncture Versus Ultrasound in Patients with Impingement Syndrome: Randomized Clinical Trial’, Physical Therapy, Vol. 65, No. 6, pp. 490 – 501, viewed 7 June 2017, www.ebsco.com, p. 491
  8. Ibid
  9. Johansson, K, Bergstrom, A, Schroder, K & Foldevi, M 2011, ‘Subacromial corticosteroid injection or acupuncture with home exercises when treating patients with subacromial impingement in primary care—a randomized clinical trial’, Family Practice, Vol. 28, pp. 355 – 365, viewed 7 June 2017, www.ebsco.com, p. 355
  10. DeBerardino, T 2016, ‘Shoulder Impingement Syndrome Clinical Presentation’, Medscape Website, viewed June 8 2017, http://emedicine.medscape.com/article/92974-clinical
  11. Ibid
  12. DeBerardino, T 2016, ‘Shoulder Impingement Syndrome Treatment & Management’, Medscape Website, viewed June 8 2017, http://emedicine.medscape.com/article/92974-treatment#showall
  13. DeBerardino, T 2016, ‘Shoulder Impingement Syndrome Medication’, Medscape Website, viewed June 8 2017, http://emedicine.medscape.com/article/92974-medication
  14. Cheng, I 2013, ‘Thawing the Frozen Shoulder—A Case Study and Clinical Recommendations for the Use of Acupuncture in Treatment of Adhesive Capsulitis’,  The American Acupuncturist, Vol. 62, pp. 25 – 29, viewed June 7 2017, www.ebsco.com, p. 25
  15. Ibid
  16. Jain T & Sharma, N 2014, ‘The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/ adhesive capsulitis: A systematic review’, Journal of Back and Musculoskeletal Rehabilitation, Vol. 27, pp. 247 – 273, viewed June 7 2017, www.ebsco.com, p. 248
  17. Cheng 2013 op.cit. p. 26
  18. Jain & Sharma 2014, loc.cit
  19. Cheng 2013 op.cit. p. 26
  20. Jain & Sharma 2014, loc.cit
  21. Cheng 2013 op.cit. p. 26
  22. Ibid
  23. Jain & Sharma 2014, loc.cit
  24. Cheng 2013 op.cit. p. 26
  25. Ibid
  26. Ibid
  27. Ibid
  28. McDonald, J & Janz, S 2017, ‘The Acupuncture Evidence Project: Plain English Summary’, AACMA Website, viewed 21 April 2017, http://acupuncture.org.au/OURSERVICES/Publications/AcupunctureEvidenceProject.aspx, p. 2
  29. Lathia et al. op.cit. p. 614
  30. Ibid, p. 615
  31. Ibid, p. 616
  32. Ibid
  33. Vas et al. 2008, op.cit. p. 888
  34. Ibid
  35. Ibid
  36. Ibid
  37. Ibid
  38. Vas et al. 2008, op.cit. p. 890
  39. Ibid
  40. Jain & Sharma 2014, op.cit. p. 268
  41. Ibid, p. 269
  42. Ibid, p. 270
  43. Kleinhenz, J, Streitberger, K, Windeler J, Güssbacher, A, Mavridis, G & Martin E 1999, ‘Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis’ (Abstract), Pain, Vol. 83, No. 2, viewed 7 June 2017, https://www.ncbi.nlm.nih.gov/pubmed/10534595
  44. Ibid
  45. Johansson et al. 2011, loc.cit.
  46. Ibid, p. 356
  47. Ibid
  48. Ibid, p. 357
  49. Ibid, p. 359

Images

Featured image – Tortora, G & Derrckson, B 2012, Principles of Anatomy and Physiology 13th ed, Wiley, USA, p. 404
Image 1 – http://kroppensterapeut.dk/testimonial/hvorfor-kravle-hvis-man-kan-gaa-uden-smerter/

About the Author:

Chris Fehres lives in Brisbane and holds a Bachelor of Health Science majoring in acupuncture. Chris completed his degree in 2015 at Endeavour College of Natural Health where he graduated with distinction and was awarded the medal of academic excellence for highest achievement Australia-wide for acupuncture. He currently holds positions at Endeavour College as a contract tutor for higher education and alumni representative for the Course Advisory Committees for both the Acupuncture and Biosciences departments, as well as having been chosen as the focus for their 2017 - 18 Graduate Stories write up.

Leave A Comment