Frozen Shoulder & Acupuncture

1. Frozen Shoulder & Acupuncture Presented by Will Sheppy

2. 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

3. 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)

4. 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.

5. 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 Dupuytren’s 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)

6. 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

7. 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)

8. 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”.

9. 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

10. 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.

11. 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.

12. 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.

13. 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)

14. 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.

15. 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.

16. 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.

17. 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)

18. 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.

19. 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)

20. 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).

21. 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)

23. 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

24. 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

25. 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