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Jing International Acupuncture Centre
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What is frozen shoulder... ?Frozen shoulder or adhesive capsulitis
is a painful condition in which the shoulder loses its range of movements. This
condition is referred to as "frozen shoulder" because it becomes very difficult
for a person to move his shoulder. The shoulder is not actually frozen, it is
just stiff. It may follow an injury to the shoulder, but may also arise
gradually without warning or injury. Symptoms of Frozen Shoulder
Normally a gradual return of motion will follow; however, the length of time for recovery from frozen shoulder can be lengthy, with an average duration of between 16 and 20 months The shoulder is a complicated joint since many muscles are involved in movement and different structures become active at different ranges of movement. For example, when the arm is raised, the first 90 degrees is performed by the shoulder and the next 60 degrees is rotation of the scapula (shoulder bone). Problems will occur with contractile structures, i.e., muscles & tendons, or non-contractile structures such as ligaments, the capsule and bursa. By palpating the shoulder & surrounding areas and testing range of movement in different directions it is possible to evaluate what is causing pain and restricted movement within the shoulder. Generally acupuncture is very effective in the treatment of shoulder problems. Acupuncture needles are inserted into the most tender areas and other needles further down the arm may be used to move energy along the affected acupuncture channel. The insertion of acupuncture needles is not painful, although some sensation will be felt; sometimes a dull achiness or heaviness in the arm, all signs that the needles are doing their work. Most pain is felt when palpating for painful areas, rather than the acupuncture itself. The term 'frozen shoulder' is a generic terms that covers a multitude of conditions. I take it to mean a shoulder that cannot be slept on. In most cases the condition referred to is 'capsulitis' and this can be felt as a 'clunk' in the joint as the arm is moved up to maximum elevation. If the capsulitis starts as the result of an accident the result is a traumatic arthritis of the joint affected. Most cases I see in the clinic have been going on for a long time and are a mixture of muscle spasm and capsular involvement. Case History - Elderly lady aged 81(1st December 2002) This patient was suffering from right shoulder pain after being mugged one year ago. Her handbag was violently pulled off her shoulder by a young man riding a bike. She had had three injections of steroids, which gave very limited relief. The hospital could not help her any further since it is not advisable to give repeated steroid injections. She had an MRI scan done privately which revealed torn muscles fibres in her shoulder muscles. Her pain was worse first thing in the morning. Treatment involved massaging the affected area (front/ back of shoulder, right arm) and needling points of tenderness on the affected acupuncture channels. Treatment was twice weekly for a couple of months. Progress was slow, with good pain relief for 1-2 days only. After two months of treatment I felt that a change of approach was needed since she wasn’t getting any permanent pain-relief. Treatment involved carefully selecting points of maximum tenderness in principal muscles and needling until I felt a ‘twitch’ within the muscle. This type of acupuncture is also known as ‘trigger point therapy’. (You can read more about this in the general introduction of ‘All Musculo-Skeletal Pain and Restricted Movement’). Immediately there was a marked improvement. At this stage treatment was weekly and she continued to improve after each acupuncture treatment. I am still treating this patient on a fortnightly basis and her shoulder is almost back to normal. This shoulder needed a lot of treatment since it had been painful for one year, had repeated steroid injections (these deplete the energy in the joint, in Traditional Chinese Medicine), and due to the age of the patient. Frozen Shoulder Definition Frozen shoulder is a condition that results in a loss of movement and pain at the shoulder joint. In frozen shoulder: Active range of motion is lost. This means you cannot move your shoulder well. Passive range of motion is lost. This means another person trying to move your arm at the shoulder joint will find it stiff and difficult to move.
Frozen shoulder gets worse over time. However, after a period of time, the shoulder may improve spontaneously. This improvement in mobility is called thawing. Causes Frozen shoulder is caused by tightening of the soft tissues, such as the capsule, that surround the shoulder joint. Risk Factors A risk factor is something that increases your chance of getting a disease, injury, or condition. Risk factors for frozen shoulder include: Diabetes Thyroid problems Disc problems in your neck Injuries to the shoulder Illness or injury that forces you to keep the shoulder immobile for a period of time Heart and/or lung disease Symptoms Symptoms include: Painful shoulder Inability to move the arm at the shoulder joint, either by yourself or by someone else
Diagnosis The doctor will ask about your symptoms and medical history, and perform a physical exam. The doctor will test the range of motion in your shoulder. Tests may include: X-rays – to rule out other possible causes of the stiffness. MRI Scan– a test that uses magnetic radiation waves to make pictures of the tissues in the body. It is used to examine the soft tissues around the shoulder. Arthrograms – x-ray pictures taken after dye is injected into the shoulder area. This test is difficult to perform with this shoulder condition. Treatment Treatment focuses on relieving pain and restoring function and range of motion to the shoulder. Non-Surgical Options Pain Relievers – ibuprofen (Advil, Motrin) and aspirin, to help reduce inflammation and relieve pain. Muscle Relaxants – to help relax arm and shoulder muscles. Physical Therapy – working with a physical therapist to stretch muscles and restore motion and function to the shoulder. This is the foundation of treatment. It requires much home exercise under the direction of a therapist. Heat and Ice Therapies – to help relieve pain and reduce swelling. Corticosteroid Injections – as prescribed and given by your doctor (Rarely done for this condition). Surgery Surgery is an option if there is no improvement after 4 to 6 months of intensive therapy. Surgeries include: Closed Manipulation – forceful movement of the arm at the shoulder joint to loosen the stiffness. This is performed under anesthesia and followed by intensive physical therapy. Arthroscopic Surgery – an arthroscope, which is a long, thin, fiberoptic tube with a light on the end, is inserted through a small incision in the shoulder. Using this tube and other small instruments, the tightened tissues are released and the shoulder is manipulated. Physical therapy must be done after this surgery.
Prevention To help prevent frozen shoulder: Do regular strength training and range of motion exercises. This will help maintain a strong and flexible shoulder joint. Seek prompt treatment for a shoulder injury. Do activities that use your shoulder joint regularly. After any injury to the upper extremity (hand, wrist, elbow, etc.), always move the shoulder through a full range of motion several times a day. This is true even when lying in bed for an illness such as a lung infection. Treatment Plus Exercise Better than Exercise Alone By Michael Devitt, contributing editor The term "frozen shoulder" is used to describe a variety of conditions that cause pain and limit the range of motion of the shoulder joint. Most commonly caused by inflammation of synovial tissue or thickening of synovial fluid, frozen shoulder occurs mainly in middle-aged people who have a history of shoulder injuries. In some cases, the pain associated with frozen shoulder can be severe enough to disturb a person's sleep; in others, patients cannot rotate the shoulder properly and have difficulty moving the affected arm out and away from the body. Once a person is diagnosed with frozen shoulder, the initial stages of care are aimed at reducing inflammation and increasing range of motion. Toward that end, various treatment methods have been devised, including anti-inflammatory drugs, ultrasound, heat, massage, and stretching and isometric exercises. Steroid injections and nerve blocks have also been employed at times, but the effectiveness of these therapies can vary greatly from patient to patient. Several studies have reported that acupuncture can successfully treat frozen shoulder, but the majority of these studies have not been of the randomized, controlled trial (RCT) variety. A new study using the RCT format compared the use of acupuncture (along with exercise) to exercise alone in a small group of frozen shoulder patients. The study, published in the Hong Kong Medical Journal, found that patients treated with acupuncture and exercise demonstrated "significantly greater improvement" on shoulder assessment tests than those using just exercise, and suggests that acupuncture could be useful in cases where more conventional therapies have been unsuccessful. Thirty-five adults diagnosed with frozen shoulder were randomly allocated to an exercise group or an exercise plus acupuncture group and treated for six weeks. Exercise patients participated in a standard group program of gentle stretching exercises under the supervision of a licensed physiotherapist. Treatment sessions lasted 30 minutes and were given twice a week for six weeks. In addition, patients were told to perform a series of shoulder exercises 10 times each morning, mid-day and evening at home during the trial period. The exercise/acupuncture group followed the same home and group exercise programs as the exercise group, but also received acupuncture twice a week during the trial. A three-inch, 30-gauge needle was inserted perpendicular to zhongping, an extra acupuncture point located on the lower leg along the stomach meridian. Zhongping was chosen based on the belief that stimulating it can "improve the flow of qi across the shoulder." A contralateral needling technique was used, in which the right-side acupoint was used for left frozen shoulder and vice-versa. The needle was inserted to a depth of 2.5 inches, followed by wide-amplitude needle rotation simultaneously with lifting and thrusting to produce de qi. The needle was retained for 20 minutes, with three one-minute needle manipulations made during the treatment period. While being needled, the patient also performed a series of functional exercises using the affected shoulder. Subjects in both groups were assessed using a test called the Constant Shoulder Assessment, which combines patient ratings for pain and activities of daily living with range of motion measurements for a maximum score of 100 points. Assessments were taken at three intervals: baseline (just prior to the start of the study); at the completion of treatment; and at 20 weeks. CSA scores were relatively equal for both groups at the beginning of the study. Within six weeks, however "significantly higher" scores were reported in patients receiving acupuncture and exercise, with an average improvement rate nearly twice that of the exercise-only group. These improvements were also seen at the 20 week follow-up test (see Table I).
Despite the relatively deep needling involved in the trial, the researchers reported that no acupuncture-related complications occurred during the course of care. However, one patient in the acupuncture/exercise group discontinued treatment after the second session due to fear of needle pain. Some limitations were noted by the investigators -- for instance, the number of exercise minutes between groups. The exercise-only group performed supervised shoulder exercises for a total of 360 minutes over the treatment period, whereas the acupuncture/exercise group performed supervised exercises for 600 minutes (360 in a group setting, 240 while being treated with acupuncture). Because acupuncture is known to relieve pain, the researchers speculated that patients who had acupuncture before exercise may have shown greater improvements because they experienced less pain during exercise. Similar concerns were raised about the size discrepancies between groups (the acupuncture/exercise group had 13 patients, while the exercise-only group had 22) and the lack of a control group to disprove the placebo effect. Despite the limits, the researchers saw promise for the use of acupuncture in conjunction with exercise to treat frozen shoulder. "The combination of acupuncture and physical exercise may be an effective option in the treatment of frozen shoulder," they wrote. "This study provides additional data on the potential role of acupuncture in the treatment of frozen shoulder, particularly for those patients not responding well to conventional therapy." They recommended that larger, placebo-controlled trials be designed to measure short- and long-term outcomes, and that a more uniform method of defining frozen shoulder be established, which would result in valid and more reliable treatments. Reference 1. Sun KO, Chan KC, Lo SL, et al. Acupuncture for frozen shoulder. Hong Kong Medical Journal 7(4):381-91.
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Pain
as the first symptom of frozen shoulder, area shown in the below picture,
followed by a loss of motion and a decrease in pain.