Frozen Shoulder & Acupuncture

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Frozen Shoulder Acupuncture

• Presented by
• Will Sheppy

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Topics

• Pathology of Frozen Shoulder
• Statistics of Frozen Shoulder
• Tradition East Asian Medical view of Frozen
  Shoulder
• Western Medical Tx of Frozen Shoulder
• Corticosteroid injection
• Physical Therapy
• TCM Tx of Frozen Shoulder
• Acupuncture
• Electro-Acupuncture

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Pathology of Frozen Shoulder

• The cause of frozen shoulder is unknown, so its
  diagnosis is based on symptom criteria.
• Arthroscopic biopsy of patients with frozen
  shoulder revealed cellular evidence of both
  chronic inflammation and proliferative fibrosis
  (Hand, 2007)

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Statistics of 223 Frozen Shoulder

• Frozen shoulder lasted about 4 years.
• It affects females more often.
• There is no arm preference.
• It is not strongly association with other
  illness.
• Frozen shoulder has a positive natural history
  and will most often resolve on its own.
• If there is an acute and severe onset prognosis
  is not as good as slow progression.
• The most common treatment is physical therapy and
  steroid injection.

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Statistics of 223 Frozen Shoulder

• The mean interval from symptom onset to
  completion was 4.4 years, range 2 to 20 years.
• Of the 223 shoulders, 137 (61) were female and
  86 (39) were male.
• The dominant arm was affected in 48 (129) and
  non-dominant in 52 (140).
• Of the 223 patients, 38(17) had high
  cholesterol, 31(14) were diabetic, 15 (7) heart
  disease, 7 (3) had Dupuytrens contracture, 6
  (3) had osteoporosis.
• Analyses of the severity of presenting symptoms
  yielded a subgroup at risk of a worse prognosis.
  Those patients who reported unbearable symptoms
  in the first 6 months had a significantly worse
  outcome compared to those who reported severe,
  moderate, or mild symptoms. Twenty-one percent of
  patients (9/42) with unbearable symptoms at onset
  went on to have persistent severe symptoms,
  compared to the 3.1 (7/227) without unbearable
  symptoms.
• Patients received a variety of treatments and
  often received more than one modality of
  treatment, including no treatment (95), steroid
  injection (139), physiotherapy (55), arthroscopic
  hydrodistension (20), manipulation under
  anesthesia (5), and arthroscopic release (5).
• Twenty percent of patients (45/223) reported
  bilateral symptoms. None occurred simultaneously.
  
• There were no recurrent cases.
• Symptoms were reported as slow in onset in 61
  (163 shoulders) and sudden in 39 (106
  shoulders).
• (Hand, 2008)

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Tradition East Asian Medicine view of Frozen
Shoulder

• Frozen Shoulder is caused by
• A Deficiency leaving an opening for cold invasion
  which lingers in the tendons and bones
• A decrease in Liver Energy and Blood
• Decent of Yang Energy

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Tradition East Asian Medicine view of Frozen
Shoulder

• The closest relationship traditional Chinese
  medicine has to frozen shoulder is Bi Syndrome
• Bi syndrome in the elderly is commonly caused by
  internal factors (deficiency of Qi and Blood).
• Deficiency Stagnation Bi syndrome
• Weak External Invasion
• (Maciocia, 1994)

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Tradition East Asian Medicine view of Frozen
Shoulder

• Frozen shoulder often occurs around the age of
  50. In Japan it is commonly known as fifty year
  old shoulder.

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Tradition East Asian Medicine view of Frozen
Shoulder

• Chapter 1 of the Neijing Suwen
• At forty-eight the yang energy of the head
  begins to deplete, the face becomes sallow, the
  hair grays, and the teeth deteriorate. By
  Fifty-six years the liver energy weakens, causing
  the tendons to stiffen.
• At forty-two all three yang-channels, taiyang,
  shoayang, yangming are exhausted, the entire face
  is wrinkled, and the hair begins to turn grey. At
  forty-nine years the ren and chong channels are
  completely empty, and the tien kui has dried up

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Tradition East Asian Medicine view of Frozen
Shoulder

• By Fifty-six years the liver energy weakens,
  causing the tendons to stiffen
• Chapter 43 of the Neijing Suwen
• Qi Bo says, When bi conditions penetrate to the
  five zang organs, death will result. When bi
  lingers in the bones and tendons, it remains for
  a long time. When bi lingers in the skin and
  muscles, it is easily resolved.

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Tradition East Asian Medicine view of Frozen
Shoulder

• At forty-two all three yang-channels, taiyang,
  shoayang, yangming are exhausted
• All the arm meridians cross the shoulder.
  However, most of the important structures of the
  shoulder are in the lateral and posterior aspects
  and are thereby governed by the arm yang
  meridians. (Legge Charles, 1999)
• Yang leaving the upper body is especially
  damaging to the shoulder because of its strong
  association with yang channels.

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Western Medical Tx of Frozen Shoulder

• Corticosteroid injections
• Steroid injections provides short term pain
  relief in frozen shoulder but benefits are not
  maintained much beyond six to twelve weeks.

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Western Medical Tx of Frozen Shoulder (research)

• Corticosteroid Injections
• Three week course of 30mg of prdnisolone daily is
  of significant short term benefit in adhesive
  capsulities but benefits are not maintained
  beyond six weeks (Buchbinder, R., Hoving, J. L.,
  Green, S., Hall, S., Forbes, A., Nash, P.,
  2004)
• Intra-articular corticosteroids injections have
  the additive effect of providing rapid pain
  relief, mainly in the first couple of weeks of
  the exercise treatment period. By the 12th week
  there was no significant difference between the
  two groups. (Bal, 2008)
• intra-articular injection of corticosteroid,
  coupled with a simple home exercise program, is
  superior to a 12 session supervised physiotherapy
  program with steroids in improving shoulder pain
  and function at 6 weeks in patients. They found
  that 12 months after enrollment, all groups had
  achieved the same degree of improvement with
  respect to shoulder pain and disability.
  (Carette, 2003)

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Western Medical Tx of Frozen Shoulder

• Physical Therapy
• Studies show that physiotherapy is good at
  increasing range of motion, but had different
  results on its treatment of pain.

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Western Medical Tx of Frozen Shoulder (research)

• Physical Therapy
• At 3 weeks, 35 of patients in the physical
  therapy group were considered to have had
  successful treatment compared with 18.6 in the
  ibuprofen alone group. There was no significant
  difference in the success rate between the two
  groups at the 12th week follow up. (Pajareya,
  2004)
• At total of 158 participants were assessed after
  joint distension at 6, 12 and 26 weeks. They
  found that physiotherapy provided no additional
  benefits in terms of pain, function, or quality
  of life, but resulted in sustained greater active
  range of motion.

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TCM Tx for Frozen Shoulder

• Acupuncture
• Acupuncture was effective at reducing pain
  whereas physical therapy was better at improving
  range of motion.
• Acupuncture also has fewer adverse reactions
  than the use of opioid analgesics,
  anti-inflammatory medications or corticosteroid
  Injections.

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TCM Tx for Frozen Shoulder(research)

• Acupuncture
• Compared with the exercise group, the exercise
  plus acupuncture group experienced significantly
  greater improvement with treatment. It was
  concluded that the combination of acupuncture
  with shoulder exercise may offer effective
  treatment for frozen shoulder. (Sun, 2001)
• The physical therapy group showed significant
  improvement in motion pain and range of motion.
  The acupuncture only group did not show any
  significant improvement in active and passive
  range of motion it did see significant
  improvement in resting and motion pain. The
  combination of physical therapy and acupuncture
  had improvement in both pain and range of motion.
  (Ma, 2006)

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TCM Tx for Frozen Shoulder

• Electro-Acupuncture
• Electro-Acupuncture is an easy way to provide
  stimulation while patient does ROM movement
• Shows similar results to acupuncture.

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TCM Tx for Frozen Shoulder(research)

• Electro-Acupuncture
• It concluded that either electro-acupuncture or
  interferential electrotherapy in combination with
  shoulder exercises is effective in treating
  frozen shoulder patients. There was no difference
  between the two interventions. The improvement
  achieved were well maintained in both
  intervention groups at least until the 6 month
  follow-up session. (Lin, M.1994)
• In another study which looked at 150 subjects
  with frozen shoulder found that combining
  electro-acupuncture with regional nerve block had
  significant higher pain control, longer duration,
  and better range of movement of the shoulder
  joint than that of electro-acupuncture or
  regional nerve block performed alone. This was a
  study performed in China. (Cheing, 2008)

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Tips For Treatment

• Use Heat
• Heat has been found to be helpful in treating
  frozen shoulder. It is suggested that deep heat
  modality increases tissue temperature and its
  extensibility, making passive range of motion
  more effective (Pajareya, 2004).

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Tips For Treatment

• Use ROM exercise
• Acupuncture reliefs pain but does little to
  increase range of motion
• It was concluded that the combination of
  acupuncture with shoulder exercise may offer
  effective treatment for frozen shoulder. (Sun,
  2001)

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Bibliography

• Books
• Beers, M.H., Kaplan, L., Berkwits, M., (eds.).
  (2006) The Merck Manual of Diagnosis and Therapy.
  Boston Merck Company, Incorporated, 2006.
• Legge Charles,(1999) Close to the Bone. New
  York Sydney College
• Maciocia, G. (1994) The Practice of Chinese
  Medicine The Treatment of Diseases with
  Acupuncture and Chinese Herbs. New York
  Churchill Livingstone
• Ni, Maoshing.(1995) The Yellow Emperor's Classic
  of Medicine A New Translation of the Neijing
  Suwen with Commentary. Minneapolis Shambhala
  Publications, Incorporated

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Bibliography

• Journals
• Hand, G. C. R., Athanasou, N. A., Matthews, T.,
  Carr, A. J. (2007). The pathology of frozen
  shoulder. The Journal of Bone Joint Surgery 89,
  928-932
• Hand, C., Clipsham, K., Rees,J. L., Carr, A. J.
  (2008). Long-term outcome of frozen shoulder.
  Journal of Shoulder and Elbow Surgery 17, 232-236
  
• Matsumoto Hiromi. (1998). Acupuncture treatment
  for Gojyukata (frozen shoulder). North Americal
  Journal of Oriental Medicine 5, 5-10
• Sun, K. O., Chan, K. C., Lo, S. L., Fong, D. Y.
  T. (2001). Acupuncture for frozen shoulder. Hong
  Kong Medical Journal 7, 381-391
• Ma, T., Kao, M. J., Lin, I. H., Chiu, Y. L.,
  Chien, C., Ho, T. J., Chu, B. C., Chang, Y. H.,
  (2006). A study on the clinical effects of
  physical therapy and acupuncture to treat
  spontaneous frozen shoulder. The American Journal
  of Chinese Medicine 34, 759-775

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Bibliography

• Journals
• Buchbinder, R., Hoving, J. L., Green, S., Hall,
  S., Forbes, A., Nash, P. (2004). Short course
  prednisolone for adhesive capsulitis (frozen
  shoulder of stiff painful shoulder) a
  randomized, double blind placebo controlled
  trial. Annuals of Rheumatic Diseases 63,
  1460-1469
• Bal, A., Eksioglu, E., Gulec, B., Aydog, E.,
  Gurcay E., Cakci A. (2008). Effectiveness of
  corticosteroid injection in adhesive capsulitis.
  Clinical Rehabilitation 22, 502-512
• Buchbinder, R., Youd, J. M., Green, S., Stein,
  A., Forbes, A., Harris, A., Bennell, K., Bell,
  S., Wright, W. J. (2007). Efficacy and
  cost-effectiveness of physiotherapy following
  glenohumeral joint distension for adhesive
  capsulitis randomized trial. Arthritis
  Rheumatism 57, 1027-10237
• Pajareya, K., Chadchavalpanichaya, N.,
  Painmanakit, S., Kaidwan, C., Puttaruksa, P.,
  Wongsaranuchit, Y. (2004). Effectiveness of
  physical therapy for patients with adhesive
  capsulitis a randomized controlled trial.
  Journal of The Medical Association of Thailand
  87, 473-480
• Carette, S., Moffet, H., Tardif, J., Bessette,
  L., Morin, F., Fremont, P., Bykerk, V., Thorne,
  C., Bell, M., Bensen, W., Blanchett. (2003).
  Intraarticular corticosteroids, supervised
  physiotherapy, or a combination of the two in the
  treatment of adhesive capsulitis of the shoulder
  a placebo-controlled trial. Arthritis Rheumatism
  48, 829-838
• Ulett, G., Han, S., Han J. (1996).
  Electroacupuncture mechanisms and clinical
  application. Biological Psychiatry 44, 129-138
• Cheing, G., So, E., Chao, C. (2008)
  Effectiveness of electroacupuncture and
  interferential electrotherapy in the management
  of frozen shoulder. Journal of Rehabilitation
  Medicine 40,166-170
• Lin, M., Huang C., Lin, J., Tsai, S. (1994) A
  comparison between the pain relief effect of
  electroacupuncture, regional never block and
  electroacupuncture plus regional never block in
  frozen shoulder. Department of Anesthesiology and
  Pain Center, Taipei Municipal Chung-Hsing
  Hospital.
• Marcus, A., Gracer R. (1994) A modern approach
  to shoulder pain using the combined methods of
  acupuncture and Cyriax-based orthopaedic
  medicine. American Journal of Acupuncture vol22
  no1 5-14