Acupuncture in manual therapy 4 the shoulder

Acupuncture in manual therapy 4 the shoulder Acupuncture in manual therapy 4 the shoulder Acupuncture in manual therapy 4 the shoulder Acupuncture in manual therapy 4 the shoulder Acupuncture in manual therapy 4 the shoulder Acupuncture in manual therapy 4 the shoulder Acupuncture in manual therapy 4 the shoulder

Musculoskeletal shoulder pain is a frequent

presenta-tion within physiotherapy, often with a multifactorial

aetiology It is a commonly treated problem in primary

care: between seven and twenty five per 1000 adults

consult general practitioners for shoulder problems

(Lamberts et al 1991); and one in every three people

experience shoulder pain at some stage of their lives

Of these, 54% of sufferers report ongoing symptoms

at 3 years ( Lewis & Tennent 2007 ) The most

fre-quent diagnosis is that of rotator cuff disease (RCD)

(van der Windt 1995); however, there is extremely poor correlation between magnetic resonance imag-ing, X-ray, ultrasound findings, and symptoms ( Lewis

& Tennent 2007 ) In addition, histological research does not provide strong evidence for an inflamma-tory tendon component associated with this condi-tion; rather, the evidence points to the potential role

of oxidative stress and the biochemical mediation of symptoms Cytokines, vascular endothelial growth factor, interleukin-1beta (IL-1), tumour necrosis fac-tor alpha (TNF-), and the neuropeptide substance

P have all been cited as potential factors involved

in tendon pathology and pain ( Lewis & Tennent

2007 ) For those whose recovery is not self-limiting, slower or incomplete, a multitude of structures can contribute to the pain mechanism that will form the foundation of the treatment hypothesis.

Donatelli (1997) refers to the shoulder as com-plex, which is composed of a number of joint struc-tures and articulations that maintain the humerus

in the joint space Integrated and harmonious links between all structures are required for full mobility and function ( Dempster 1965 ) The synchronized movement of four joints must occur for elevation

to take place and for function to be achieved

l Glenohumeral;

l Scapulothoracic;

l Sternoclavicular; and

l Acromioclavicular ( Fig 4.1 ).

It is necessary for the manual therapist to have a comprehensive understanding of functional biomechan-ics, movement phases, muscle imbalance, and injury

CHAPTER CONTENTS

Background 57

Mechanisms of myofascial pain 59

Rotator cuff disease 59

Muscles involved 60

The supraspinatus muscle 60

The infraspinatus muscle 61

The subscapularis muscle 62

What if inflammation is present? 63

Return of normal shoulder movement 65

Muscle imbalance re-education 65

Re-establishment of movement synchrony 66

The unresolving shoulder 66

Chronic shoulder pain and stiffness .67

References 72

4

The shoulder

Jennie Longbottom

pathology, including trauma, microtrauma, or disease

processes that may interfere with any of the movement

mechanisms giving rise to pain and dysfunction:

‘Acupuncture may be more or less effective for different

pain types; therefore diagnosis of the predominant pain

mechanisms should always underpin treatment decisions

and prognosis.’ (Lundeberg & Ekholm 2001)

It is essential that relevant pain presentation

mechanisms are addressed with the help of manual

therapy, electrotherapy, and acupuncture

interven-tion; once pain is under control, functional

reha-bilitation is facilitated ( Lewis 2007 ) We cannot

expect patients to enter into a therapeutic alliance

without understanding how and why we are trying

to achieve pain modulation; similarly, we must ask

whether it is correct to treat the pain presentation

if we do not understand the mechanisms ourselves

Assessment of these mechanisms is crucial for the

development of the hypothesis that will dictate

whether the manual or acupuncture intervention is

to be effective ( Lundeberg & Ekholm 2001 ) Consider some of the structures involved in shoulder dysfunction:

l Anatomical abnormalities such as congenital acromial osteophyte variations;

l Poor scapula control;

l Shoulder instability whether through hypermobility, trauma, or RCD; and

l Poor glenohumeral, scapulothoracic, or shoulder girdle mechanisms.

The shoulder is an inherently mobile complex, with varying joint surfaces allowing the freedom of movement, and vast mobility occurs at the expense

of stability ( Donatelli 1997 ) Because there are over

20 muscles acting upon the joint to provide stabil-ity, the possibility of pain provoked from myofascial structures should never be overlooked Indeed, it is recommended that this may well be the first line

Acromioclavicular joint

Subacromial space Sternoclavicular joint

Glenohumeral joint Scapulothoracic joint

Head of humerus Humerus

Ribs

Coracoid process Clavicle

Figure 4.1 l Shoulder complex

of investigation since restoration of full movement

and full stability cannot occur if the muscle

com-ponent is the pain-provoking structure ( Ceccherelli

et al 2001 ) Restoration of full muscle balance

can-not occur with the presence of a dysfunctional

motor end-plate, which prevents full muscle length

A shortened, abnormal muscle length will result in

pain provoked by loading of the muscle, a

charac-teristic presentation of myofascial pain involvement

and resulting muscle weakness.

Mechanisms of myofascial

pain

Mechanisms of myofascial pain occur as a result

of nociceptor stimulation in peripheral tissues via

mechanical structures associated with conditions

such as:

l Impingement;

l Entrapment;

l Bony abnormalities; and

l Mechanical pressure.

The alleviation of nociceptive or myofascial pain

must be directed towards the tissues causing this

pain The source of dysfunctional tissues involved

can only be revealed by careful assessment and

elimination; similarly, the mechanism of

acupunc-ture can only be effective if treatment targets the

structures involved The presence of active

myofas-cial pain can result in:

l Increased acetylcholine at the motor end plate;

l Shortened muscle fibres, ischaemic and/or

mechanical pressure on associated blood

vessels; or

l Increased production of cytokines and substance

P within the area.

If any of the above is the cause, then the aim of

acupuncture intervention must be:

l To deactivate the myofascial trigger point

(MTrPt);

l To restore muscle length and relaxation;

l To restore blood flow; and

l To assist in the removal of

neuropeptide-aggravating chemicals.

Patients will clearly report a myofascial

compo-nent to their pain if they describe:

l Pain aggravated on muscle loading;

l Pain eased on off-loading;

l Pain eased by touch, heat or ice, indicating an ischaemic component;

l Pain referred along a given muscle referral pattern; and/or

l Reproduction of pain on palpation of tender spot

or taut band.

If any of the above is involved in the pain presen-tation, then a full myofascial assessment with a subse-quent TrPt deactivation of the myofascial component

is the first requirement for the needle application whether in the rotator cuff and/or cervical muscles.

Rotator cuff disease

Rotator cuff disease (RCD) represents the most common cause of modern shoulder pain and disabil-ity Much of the clinical literature on RCD focuses

on subacromial impingement and supraspinatus tendinopathy, although other patterns of lesions are also recognized Both extrinsic and intrinsic factors

to the cuff tendon are thought to be involved in the pathogenesis, leading on to a spectrum of condi-tions ranging from subacromial bursitis to mechani-cal failure of the cuff tendon itself ( Barying et al

2007 ) Careful history and examination followed

by pertinent investigation are essential to establish the correct diagnosis The main aim of treatment is

to improve symptoms and restore the function of the affected shoulder.

There is no definitive evidence for the efficacy of physical therapy interventions in the management of RCD ( Al-Shenqiti & Oldham 2005 ) Myofascial pain syndromes are common conditions that result from active TrPts ( Sola et al 1955 ) Myofascial pain has two important components: motor dysfunction of the muscle, and sensory abnormality characterized

by either local or referred pain ( Whyte-Ferguson & Gerwin 2005 ) There are a number of clinical diag-nostic characteristics that may be presented dur-ing assessment that can be used to confirm and/or exclude the presence of MTrPts The reliability of TrPt identification has been the subject of much criticism ( Bohr 1996 ), but the reliability of physi-cal signs is essential to obtaining meaningful cliniphysi-cal information ( Al-Shenqiti & Oldham 2005 ; Nice et al

1992 ) These indicators include: spot tenderness, pain recognition, and referred pain pattern.

Patients demonstrating diagnostic rotator cuff tears

on magnetic resonance imaging (MRI) investigation

may respond favourably to the deactivation of TrPts,

but it is essential to understand both the

anatomi-cal presentation of pain and the muscles commonly

involved ( Fig 4.2 ) It is equally important to adopt

rigor and standardization of assessment in order to

eliminate the contributing myofascial pain component

of rotor cuff pain presentation The TrPts must be

deactivated prior to shoulder stability exercise,

pos-tural and ergonomic retraining, and any future muscle

imbalance and scapula retraining The most common

TrPts are found in the infraspinatus muscle, whilst

the subscapularis is least affected muscle in RCD

(Al Shenqiti & Oldham 2005).

Muscles involved

The supraspinatus muscle

A major function of the supraspinatus (Figs 4.3 and 4.4) is to maintain balance amongst the other rotator cuff muscles and therefore offer stability to the joint A common clinical symptom is ‘a catch’

of severe pain whilst the movement of elevation is attempted, with a positive Neer or Hawkins sign,

or both Pain is referred to the mid-deltoid region, extending to the arm and forearm if severe, espe-cially at the lateral epicondyle of the elbow It may often be mistaken for subdeltoid bursitis or later

1 2

3

4

Suprascapular nerve Suprascapular nerve

Axillary nerve

Subscapular nerve

1

Origin Muscle

Supraspinous fossa

of the scapula

Greater tuberosity

of the humerus

Abduction

Suprascapular nerve (C4–C6)

Insertion Action Innervation

2 Infraspinous fossaof the scapula Greater tuberosityof the humerus External rotation Suprascapular nerve (C4–C6)

3 Lateral border of the scapula Greater tuberosityof the humerus Abduction Axillary nerve (C5,C6)

4

Supraspinatus

Infraspinatus

Teres minor

Subscapularis Subscapular fossaof the scapula Lesser tuberosityof the humerus Internal rotation Subscapular nerve (C5–C6)

Figure 4.2 l The muscles of the rotator cuff

epicondylitis ( Simons et al 1999 ), but in reality, the

supraspinatus muscle is in direct contact with the

bursa and, hence, we are presented with

nocicep-tive sensitization It is necessary to undertake TrPt

release and manage the patient with appropriate

stretching and muscle re-education This muscle

should not be stretched if related RCD processes

are present ( Fig 4.5 ).

The infraspinatus muscle

Infraspinatus injury is a common presentation

char-acterized by deep, intense pain at the anterior edge

of the shoulder within the bicipital groove, radiating

down the radial aspect of arm and forearm, and it

A

B

Figure 4.3 l Supraspinatus pain referral pattern

Lateral to medial needling for musculo-tendinous junction

Medial to lateral needling across supraspinatus fossa

Figure 4.4 l Direction of trigger point needling for

supraspinatus muscle

is identified as a major source of arm pain (Figs 4.6

and 4.7) ( Travell 1952 ) The pain is associated with

abduction and medial rotation, and is most

com-monly a result of the acute overload associated with

whiplash injury If joint restriction accompanies the

trigger point, then mobilization of the

acromiocla-vicular and sternoclaacromiocla-vicular articulations may be

required If there is suspicion of rotator cuff

dam-age, the infraspinatus should not be stretched, but

sustained myofascial contract–relax should be used

( Fig 4.8 ).

Isolated posterior pain is usually not involved in

a single muscle pain presentation However, if the

patient complains of dysaesthesia in the fourth and

fifth fingers, this may well be attributed to a

sin-gle muscle element ( Escobar & Ballesteros 1998 )

This is usually the result of overload stresses, and

repetition of upward reaching and extension of the

shoulder, commonly associated with window

clean-ing Its action is often coupled with the

infraspina-tus, and it is necessary to deactivate both muscles

before any muscle imbalance retraining.

The subscapularis muscle Subscapularis trigger point pain referral presents with posterior scapula and shoulder pain in the form of a ‘watchstrap band’ of pain on the affected arm ( Fig 4.9 ) ( Zohn 1988 ) The subscapularis medially rotates and adducts the arm and patients initially have pain on medial rotation and abduc-tion; for example, when throwing a ball or playing golf It can also manifest in patients following hemi-plegia Gradually abduction is restricted to below 45° and is often diagnosed as frozen shoulder The subscapularis is often overlooked in shoulder dys-function ( Donatelli 1997 ; Simons et al 1999 ) It has a large and relatively inaccessible muscle mass that serves to sensitize the other rotator cuff mus-cles, which often develop latent TrPts This leads to loss of rotation and pain patterns that may mimic joint range of movement loss, especially in lateral rotation Management aims to identify the factors involved, whilst pain management remains a prior-ity because pain leads to inhibition of rotator cuff

Stretch excercise 1: Supraspinatus Stretch excercise 2: Supraspinatus

Figure 4.5 l Stretching exercises for supraspinatus muscle

and shoulder weakness ( Donatelli 1997 ; Itoi et al

2007 ) The goals of the rehabilitation process should include:

l Reduction of TrPt dysfunction;

l Return of normal shoulder movement;

l Muscle imbalance re-education;

l Re-establishment of movement synchrony; and

l Progressive return to function.

What if inflammation is present?

Although the evidence for the presentation of inflammatory processes in RCD is poor, there are some indications that these processes are present

A

B

Figure 4.6 l Infraspinatus muscle pain referral pattern

Figure 4.7 l Direction of needling for infraspinatus

muscle

in cases of acute injury Acupuncture is thought

to have a modulating effect on both the systemic

and peripheral mechanisms implicated in

neuro-genic inflammation ( Ceccherelli et al 2002 ) After

stimulation with acupuncture, calcitonin gene-related peptide (CGRP), substance P, and beta-endorphin are all released ( Raud & Lundeberg 1991 ) Substance P initiates mast cells and macrophages

Figure 4.8 l Stretching for Infraspinatus muscle

Figure 4.9 l Subscapularis pain referral pattern

to secrete inflammatory mediators; CGRP

stimu-lates vasodilatation and thus induces peripheral

events, improving tissue function and pain relief

If the acupuncture is too intense and too frequent,

it can result in overstimulation of substance P and

CGRP, causing a proinflammatory effect Well-

performed acupuncture (obtaining de Qi) that

is low dose and frequently applied (two or three

times per week for 10 to 20 minutes) using points

distal to the injury site, at the segmental dorsal

horn or on the contralateral side ( Bradnam 2002 )

at the start of the injury process, could provoke a

sustained low-dose release of CGRP with

result-ing anti-inflammatory effects ( Sandberg et al 2004 )

and without activation of proinflammatory agents

( Raud & Lundeberg 1991 ) This offers a case for

promoting early acupuncture intervention at the

acute stage of the inflammatory process How

often have we turned to acupuncture after three

or more treatments when pain modulation has not

been met? If inflammation and pain are preventing

manual intervention and active return to function,

then acupuncture should be considered within the

first few treatments to promote cortisol release,

increase blood flow, and facilitate manual

interven-tion and rehabilitainterven-tion (Tables 4.1 and 4.2) Distal

points, He-Sea points, and Qi Cleft points should

all be considered for the activation of Qi and blood

flow and for the promotion of homeostasis and

healing Qi Cleft points are referred to in

tradi-tional Chinese medicine (TCM) for the treatment

of acute conditions where inflammatory agents are

causing pain, swelling, and limited movement It is

common to choose Qi Cleft points that correspond

to the injury site and affected meridians.

Return of normal shoulder

movement

Normal movement may be restored by a variety of

therapeutic means, including: proprioceptive

train-ing; stretchtrain-ing; and a range of movement (ROM)

home exercise programme.

Muscle imbalance re-education

There are no significant differences between

patients who are given customized exercises and

those who are given standard exercises on meas-ures of pain, intensity, functional status, shoulder ROM, and strength ( Wang 2004 ) The best exer-cise protocol for RCD or subacromial impinge-ment syndrome (SIS) has not yet been established, although the benefit of subjecting patients to a reinforcement programme for the glenohumeral and scapulothoracic muscles to improve joint sta-bility, reduce pain, and regain strength is gener-ally accepted Rehabilitative programmes based on either non-specific or specific exercises seem to give favourable results but further research is nec-essary in order to verify which protocol is the most effective Stretching is often proposed to be asso-ciated with re-enforcement exercises to lengthen shortened muscular and ligamentous structures, and manual therapy has been demonstrated to be

a valid instrument for reducing in the impingement syndrome At the moment, muscular reinforcement

Table 4.1 Suggested points for increased blood flow Points Traditional Chinese

medicine

Western

SI3 Alleviates pain in arm and face

Clears heat

Upper quadrant pain

LI4/5 Alleviates pain Expels pathogens

Alleviates pain and swelling in upper extremity LI11 Arm pain

Stimulates Qi flow in LI meridian

Increases blood flow in the meridian

GB20 Removes pain and heat in the area of neck and arm

Increases blood flow to head and neck LIV3 Alleviates pain and

induces relaxation GV14 Moves Qi and alleviates stiffness

Increases blood flow to head and neck BL40 He-Sea point of meridian Increases blood flow in

meridian BL60 Removes heat and

activates the channel BL62 Activates channel and alleviates pain ST44 Alleviates pain and swelling

Alleviates pain and swelling in lower extremity ST36 Tonifies Qi

Nourishes blood

is the recommended approach for an impingement

syndrome and instability problems because of the

dependence of the scapulohumeral girdle on the

surrounding muscle ( Casonato 2003 ).

Re-establishment of movement

synchrony

Re-establishment of movement synchrony is

nec-essary to restore the patient to previous

perform-ance and functional levels In the case of the

athlete, the development of a throwing or activity

programme that pertains to the individual sport

is necessary, and with this, a progressive return to

function simulating sport activity in the resisted

exercise programme If a build-up of

inflamma-tory neuropeptides aggravating the peripheral

pain mechanisms is the cause, then acupuncture

using distal, He Sea, or Qi Cleft points may well provide the modulating effect to facilitate cortisol release and blood flow, thus enhancing rehabilita-tion However, if the pain nature is caused by myo-fascial structures, a variety of other factors must be explored.

The unresolving shoulder

Patients are often referred to physiotherapy with the catch all diagnosis of frozen shoulder (FS) ( Neviaser 1945 ), which is loosely defined as a painful, stiff shoulder, varying in duration from several weeks to several months Pain, along with diminished function, usually motivates the patient

to seek help ( Cailliet 1981 ; DePalma 1983 ) It is essential to eliminate any cervical or thoracic spine involvement along with acromioclavicular, sterno-clavicular, and scapulothoracic dysfunction, or first rib involvement Although there is little agreement

on treatment protocols, the goals for rehabilitation remain clear, namely, pain relief and restoration of function Pain tends to be more long standing, radi-ating beyond the shoulder joint and involving sleep disruption; therefore, the aim of acupuncture inter-vention should be directed towards activation of descending inhibitory mechanisms involving:

l Pain modulation;

l Sleep enhancement;

l Well being; and

l Functional restoration.

Within TCM, FS is referred to as Jianning and belongs to the yin group of disease patterns known

as Bi syndrome ( Sun & Vangermeersch 1955 ), or painful obstructive syndrome ( Maciocia 1994 ) It is mainly confined to superficial meridian or channel blockage, stagnation or obstruction caused by an attack of pathogenic factors such as cold (Han Bi), dampness (Shi Bi), or wind (Feng Bi) or a combi-nation of all three External pathogens will only invade the channel when defensive Qi (Wei Qi)

or internal organ Qi and/or blood is weak, and cannot counteract the stronger pathogen factor Within the flow of Qi dynamics, joints are impor-tant areas of convergence of Qi and blood Through the joints, yin and yang Qi meet ( Maciocia 1994 ),

Qi and blood enter and exit, and pathogenic factors converge after penetrating the channels causing

Table 4.2 Suggested points for enhancing acute

symptom resolution

Points Area supplied Suggested conditions

LU6

PC4

HT6

Palmer aspect of

wrist and forearm

Acute swelling and inflammation to contralateral wrist and forearm

Tendinosis of wrist flexors Repetitive strain injury Distal points for shoulder/

elbow injury LI7

SJ7

SI6

Postero-ulnar aspect

of wrist and forearm

Acute swelling and injury to contralateral wrist

Extensor tendinosis Repetitive strain injury Distal points for shoulder/

elbow injury ST34

GB36

SP8

LIV6

KID5

GB35

Acute knee injury,

swelling and stiffness

Sports injuries

All soft tissue injuries

Acute flare up

of inflammatory

processes

Contralateral knee if area within point location swollen May be used as distal points

if outside the area of swelling

BL63

BL59

KID8

KID9

Acute ankle or lower

limb injury

Shin splints

Contralateral ankle if area within point location swollen May be used as distal points

if outside the area of swelling hip and knee pain