This Acupuncture case study explores the current research available to support acupuncture as an adjunct to Physiotherapy/Sports therapy when treating unilateral shoulder pain.
Patient X was convinced only surgical intervention would resolve her pain due to previous negative experiences with Physiotherapy.
Treatment included Acupuncture to desensitise local tissues and normalise afferent input, as well as dry needling to eliminate active trigger points. Rehabilitation involved posture-related exercises and scapula stability strengthening to address the predisposing factors to pain, as well as prevent reoccurrences of future episodes. Patient X became receptive to Physiotherapy intervention and was able to return to work.
Physiotherapy, Sports therapy, Scapula dyskinesia (SD), Active Trigger Points (ATP), Latent Trigger Points (LTP), Acupuncture, and Dry Needling.
Shoulder pain is a common musculoskeletal injury resulting in reduced function and an inability to work (Brukner and Khan, 2007). In the health care profession, shoulder pain is often directly linked to workplace activities and can be made worse by work (Health and Safety Executive, 2012).
Health care professionals undertaking diagnostic imaging work using ultrasound equipment have a high prevalence of upper limb disorders (Health and Safety Executive, 2012). Village and Trask (2007) identify one-sided static working position, prolonged pinch gripping of the transducer, abduction of the shoulder during transducer placement and insufficient recovery time between clinics, as factors increasing the risk of injury. Implications of injury vary from time off work, to leaving the profession (Brown and Baker, 2004).
The Health and Safety Executive (2012) identifies the importance of risk assessments to reduce the risk of injury. Modification of activities which exacerbate pain is recommended by the National Institute of Clinical Health and Excellence (NICE) (2012). NICE (2012) recommends that patients suffering from shoulder pain are referred to Physiotherapy. The Chartered Society of Physiotherapy (2013) supports early Physiotherapy management to reduce sickness absence costs associated with work-related injuries, which are estimated at fifteen billion pounds annually (Department of Work and Pensions, 2011).
Case Study Introduction
Patient X is a 54-year-old Sonographer complaining of chronic right shoulder pain, lasting six months.
Peripheral sensitisation results from persistent nociceptive activation (Schaible, 2007). Noxious stimuli (mechanical, thermal and chemical) activate primary nociceptive neurons (Kawakita, 1993). In response, nociceptors release neuropeptides (such as substance P and calcitonin gene-related peptide (CGRP)) from their sensory endings.
Nociceptors synapse with second-order neurons in the grey matter of the dorsal horn. Axons ascending to the brain stem generate a conscious pain response (Schaible, 2007). Pain avoidance movement patterns, such as SD, are attributed to nociceptive motor reflex response to pain; this suggests the SD identified in patient X is a consequence of pain.
When pain is chronic, tissues become sensitised. Mechano-insensitive nerve fibres become mechano-sensitive as the excitation threshold detecting sensitivity drops (Schaible, 2007). A reduction in the threshold means nociceptors in muscle show pronounced sensitisation to mechanical stimuli (Mense, 1993). This explanation is fitting to patient X’s presentation, as all movements in the shoulder have become painful.
In sensitised tissues, resting discharges are induced, thus increased nociceptor activation creates a continuous afferent barrage into the spinal cord (Schaible, 2007), which elucidates why Patient X complained of constant pain, even when the patient is not moving.
There is also the possibility that previous trauma had left the area sensitised. Schaible (2007) has identified that previous trauma to a tissue site can cause ectopic discharges due to impaired nerve fibres. Changes in the A-beta fibres evoke exaggerated responses in the spinal cord neurons, therefore additional sensitisation could be related to patient X’s previous rotator cuff injury.
Repetitive and overused muscles, poor posture and disturbed movement patterns highly correlate to myofascial trigger points (Brukner and Khan, 2007). Trigger points alter motor activation patterns and cause kinematic disturbances (Bron et al., 2011). Patient X presents with SD, it could be hypothesised that trigger points rather than pain are the origin of this objective observation.
Trigger points are local points sensitive to pressure (Bron et al., 2011). It is commonly agreed that trigger points can either be active or latent (Baldry, 2005). ATPs reproduce pain when compressed and elicit a twitch response when needled (Bron et al., 2011). LTPs are bands of taut muscle which are painful when palpated. LTPs can also increase muscle tension and restrict the range of motion. They may develop in the synergist or antagonist as a result of overloading or compensation for weak muscles, or shortening of the fibres affected by the ATP (Baldry, 2005).
There are two main theories used to explain the formation of trigger points:
The motor endplate theory links the increased amounts of acetylcholine causing dysfunction within the nerve ending. Trigger points are located in the motor endplate zone in the centre of muscle fibre; at this juncture the motor nerve divides into a number of branches. Baldry (2005) proposes the branching nerve endings containing motor endplates, hold neurovascular bundles consisting of nociceptive and proprioceptive sensory afferents. Normally a nerve action potential causes the release of acetylcholine from the motor endplate predisposing a muscle contraction. When nociceptors become sensitised, the liberation of CGRP is brought about by an excessive release of acetylcholine (Russo and Brose, 1998). This generates abnormal patterns of motor endplate activity, thus muscle fibres become markedly contracted, forming a trigger point.
A second theory links a trigger point to increased muscle demand through either increased load or trauma. Trigger point activity may arise in muscles that have become ischemic and hypoxic due to arterial obstruction. Limited perfusion affects the efficiency of the calcium pump within a muscle fibre. Increased intercellular calcium levels and a shortage of adenosine triphosphate (which releases myosin cross-bridges) result in continuous activation of actin and myosin (Hong, 2000), forming a trigger point.
Inserting a needle directly into a trigger point is thought to be an effective way of influencing sensitised nociceptors (Itoh et al., 2004). The purpose of needling is to increase circulation and decrease acetylcholine levels to normalise the physiological function of the motor endplate (Itoh et al., 2004). Insertion of the needles into trigger points causes a twitch response (Itoh et al., 2004), this results in a localised stretch relaxing the contracted fibres (Langevin et al., 2001).
Neuropeptides are released from afferent nerve terminals in response to acupuncture influencing vasodilation of capillaries and vessels (Jansen et al., 1989). Acupuncture may then stimulate the healing of injured tissues.
Whilst dry needling directly affects tissues at a cellular level, stimulation of sensory afferents using acupuncture points evoke local, spinal segmental and supraspinal reactions within the central nervous system (Bradnam, 2011).
Acupuncture affects the sensory, autonomic, endocrine and immune systems (Andersson and Lundeberg, 1995), and modulates cortical excitability influencing the motor system (Lo and Fook-Chong, 2005). Stimulation of sensory afferents produces spinal effects causing strong analgesic responses (Andersson and Lundeberg, 1995). Spinal points can be used to influence the appropriate segment via the dorsal rami (Bradnam, 2003).
In chronic pain states, pain does not reflect tissue damage, rather psychological and social factors seem to influence pain appreciation (Kendall, 1999). There is strong evidence that negative emotional states have a detrimental effect on physical health (O’Connor et al., 2009). Mal-adaptive and pain-related coping strategies, such as yellow flags are important to identify. Patient X presents with yellow as well as blue flags (these relate to emotion and work problems respectively), these require consideration during treatment.
Sensory inputs are integrated with emotional awareness within the brain regions, processing the “affective emotive” component of sensation (Seifert and Maihofner, 2009). Interactions between the limbic system and the prefrontal cortex provide a pathway for the conscious awareness of emotions which drive physical responses and behaviour (Seifert and Maihofner, 2009).
Physical and emotional stress is associated with the decreased limbic system and prefrontal cortex control over anti-inflammatory cortisol regulation (Dedovic et al., 2009). Negative moods affect the processing of visceral sensations in the brain leading to symptoms such as irritable bowel syndrome. The influence of emotional health on physical health needs to be valued.
Acupuncture is considered an interoceptive stimulus. It assists by normalising the internal sensory representation and associated emotional response to a pain stimulus (Napadow et al., 2009). Normalising afferent input helps to alter the perception of pain through emotional circuits (Bradnam, 2011).
Please see appendix two for the specific treatment given and rationale for each appointment.
Whilst validated outcome measures are important to clinical research the use such one was not used in this case study. Instead, the numerical rating scale was used to indicate a change in pain; subjective percentage improvement was used between treatments to indicate the patient’s perception of improvements. Active range of motion of the shoulder and SD were re-assessed to evaluate physiological changes in relation to treatment.
The presence of pain and stiffness in the shoulder can lead to an inability to work as well as decreased function (Dolder et al., 2012). Return to work was agreed upon as a key milestone for patient X.
Scapula stabilisation and posture were also addressed during physiotherapy treatment. In order to restore scapular kinematics, thoracic extension mobility needed to be increased, and pectoralis minor stiffness decreased. A stable scapula allows muscles to maintain their optimal length-tension relationship (Brukner and Khan, 2007). This is important for patient X to prevent the reoccurrence of trigger points.
A referral to the Ergonomic Assessor lead within the workplace was completed as advised by the Health and Safety Executive (2012).
Two relevant studies have been used to support acupuncture as an adjunct to Physiotherapy intervention for patient X. Osborne and Gatt (2010) found that dry needling of trigger points increased range of motion, reduced pain and improved strength in patients complaining of shoulder pain. Itoh et al. (2013) reported a reduction in pain and improved function in patients complaining of chronic shoulder pain.
Both studies used subjects comparable to patient X. Osborne and Gatt (2010) assess the effectiveness of needling of trigger points caused by repetitive overuse movements. This is similar to the repetitive scanning movements causing patient X pain. Itoh et al. (2013) assessed acupuncture effectiveness in patients complaining of chronic shoulder pain; again this is comparable to patient X.
Osborne and Gatt (2010) conducted a case study trial. Advantages of case studies include low-cost budgets and quicker completion compared to other designs (Lewallen and Courtright, 1998). As a result, case studies tend to use low subject numbers and are at risk of author bias, which in turn reduces the validity of a study. Case-control studies are sometimes less valued for being retrospective (Lewallen and Courtright, 1998).
Itoh et al (2013) completed a preliminary randomised control trial. Subject participants and examiner blinding was carried out to reduce bias. The efficacy of subject blinding was also carried out in this study. A randomised control trial is considered the most stringent way of determining whether a cause-effect relation exists between the intervention and the outcome (Sibbald and Roland, 1998).
The methodology of the case study completed by Osborne and Gatt (2010) is greatly flawed. Only four subjects were used, a small sample size lowers the generalisability of study findings (Creswell, 2013). Furthermore, due to the nature of the study, inclusion and exclusion criteria were not used. It is therefore unknown if other variables within the subject population (such as neurological disorders or conflicting ongoing treatment) had an influence on the results obtained. This reduces the reliability of findings in the study (Creswell, 2013). The study used outcome measures including active range of motion, pain and strength to dictate the effectiveness of the acupuncture trial. These outcome measures are all clinically relevant as they are used in everyday practice. Detailed measurement procedures increase the repeatability and therefore the reliability of this study. Data was collected by subjects immediately after they had played a game of volleyball. The timing of the data collection allowed subjects to reflect immediately on the pain experienced during a functional task, however, the study did not reveal whether the subjects (volleyball players) had won or not, the study took place during an international tournament therefore perhaps the outcome of the match may have influenced subjects pain scores. Finally, data analysis is not statistically analysed, this reduces the validity of the results obtained in the case study (Creswell, 2013).
Itoh et al. (2004) used a slightly larger sample size consisting of seventeen subjects (one subject withdrew), similarly, a small sample size reduces the generalisation of findings. It is unclear exactly how subjects were recruited for the trial. A vague description of subject recruitment means researcher bias cannot be fully excluded. A detailed inclusion and exclusion criteria were provided. Subject randomization, along with examiner and participant blinding increases the validity of this trial. A detailed methodology increases the repeatability of this trial and overall validity (Creswell, 2013). Trigger point diagnosis was assessed by palpation of taut bands. It is well documented that trigger points are identified when compression produces pain, and it is commonly recognised that taut bands may or may not produce pain depending on whether they are active or latent. This means that the diagnostic criteria to identify trigger points is less comparable to other research studies and reduce its application clinically. Outcome measures such as pain and pain disability were tested using the VAS and Constant-Murely Score respectively. These tests were completed for baseline assessment and then at intervals up to twenty weeks post initial treatment. A longer follow up period in this study provides insight into the effectiveness of acupuncture in both the short and long term. Data were statistically analysed increasing the validity of the results obtained (Creswell, 2013).
Both studies (Osborne and Gatt, 2010; Itoh et al., 2013) support the use of acupuncture as a treatment for shoulder pain. Both subject groups were very different but comparable to patient X. Limitations are identified in both studies highlighting the need for better quality trials with larger sample sizes.
A combination of dry needling and acupuncture was used in this case study with the intention of optimising supraspinal effects as well as targeting trigger points directly. However, there is limited evidence available supporting the use of a combination approach in chronic shoulder pain.
Acupuncture was indicated due to the biopsychosocial factors identified in patient X.
Biopsychosocial factors are identified in patients in everyday life, making conclusions from this study more relevant clinically.
Brukner and Khan (2007) suggest trigger points should not be needled more than twice in one week. Patient X was needled twice in a week, and therefore perhaps the patient received more treatment than necessary. Reducing treatment frequency would free up time in a clinic diary allowing an increased number of appointments and thus reducing waiting list time. Lack of awareness with regard to treatment frequency has been acknowledged in this case study.
This study is limited because it is a single case study. It was also completed by an inexperienced acupuncturist; therefore this reduces the quality of findings. The used of a valid outcome measure would have improved the validity of this case study.
However, overall, patient X improved and returned to work suggesting acupuncture contributed to the improvement in this particular patient.
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Subjective and Objective findings
Patient X is a 54-year-old female complaining of right shoulder pain. She initially saw her General Practitioner (GP) six months ago after she noticed a gradual onset of pain over a four week period. Her GP referred her to an Orthopaedic Consultant (who she had been under three years ago). Three years ago the patient fell whilst gardening, she required a small rotator cuff repair to her supraspinatus tendon. Patient X reports the GP initially wanted to refer her straight to Physiotherapy, however, she insisted on seeing her previous Consultant as she thought she has re-injured her shoulder tendon. The Orthopaedic Consultant arranged a Magnetic Resonance Imaging (MRI) to assess the injury in the patient’s shoulder. The MRI came back clear; nothing abnormal was discovered. The MRI excluded inflammation within the shoulder complex. The patient asked the Orthopaedic Consultant for another MRI as she felt something had been missed or the report was written for a different person. The Orthopaedic Consultant then referred patient X to Physiotherapy.
Patient X had had negative experiences with Physiotherapy in the past. When she injured her shoulder three years ago, she was told by a Physiotherapist she had a low pain threshold and that she had no damage to her shoulder. The physiotherapist in the past had misdiagnosed her rotator cuff tear three years ago; therefore Patient X was reluctant to comply with Physiotherapy.
Patient X works is a nurse in a maternity department; she has recently taken two weeks off sick due to her shoulder pain as she is having difficulty at work. Her duties at work include running regular obstetric ultrasonography clinics for internal examination of pregnant women. Patient X is concerned her pain will worsen. She is having difficulty accepting the MRI did not conclude any underlying pathology or re-injury.
Active range of movement for the 54-year-old female
- Flexion ¾
- Abduction ¾
- Hand behind head ¾
- External rotation of shoulder with arm beside body ¾
- Extension full range of motion
- Shoulder impingement test: positive
- Rotator cuff strength: 5/5
- Flexion: right shoulder pain/tightness end of range
- Rotation to right: ¾ pain end of range
- Neural tension: NAD
Right arm dominant
- Full passive shoulder range of motion, although end of range stiffness with abduction and flexion.
- Six-month history of shoulder pain
- Scapula dyskinesia with glenohumeral joint abduction and flexion
- No mechanism of injury or trauma, gradual onset. Initially, only abduction was painful, now all movements are
Difficulty sleeping due to discomfort and positioning (normally sleeps on her right side, unable to do this). Reduced thoracic extension active range of motion. Thoracic spine palpation: no pain, however very stiff throughout.
MRI: Nothing abnormal discovered
- Aggravating factors: Sonography at work, unable to do gardening or decorating at home. Difficulty lifting and carrying shopping. Driving cause pain
- Easing factors: Rest, heat and hot baths, pressing on the painful area
Previous Medical History
- Three years ago she had a small supraspinatus tear, treated surgically.
- Irritable Bowel Syndrome
On palpation of soft tissue
- Taut bands on upper, middle and lower fibres of the trapezius.
- The upper trapezius trigger point recreates pain into the base of the occiput.
- Active trigger points with palpation of the infraspinatus, causing the referred pain in her right upper arm.
- Supraspinatus has a latent trigger point
- The patient is convinced something has been missed and the MRI has not been reported accurately
- The patient had a bad experience with physiotherapy in the past with regards to misdiagnosis
- She is very tense and has elevated shoulder levels. She is able to relax, but finds it difficult to do so
- Blue flags: Already taken time off work, feels she cannot work and is unlikely to return to work.
- Protracted shoulder posture
- Increased thoracic flexion
Date Treatment given Outcome Adverse reaction
05.06.14 Dry needling: Trapezius ; IFS; SS
- Twitch response and referred pain with traps
- Referred pain with IFS
- Local pain with SS
Trigger points are diagnosed in association with pain, restricted movements, weakness, sleep disturbance and tender nodules (Simons et al., 1999). Identification of trigger points is performed through palpation. Bron et al. (2007) confirmed that this is a reliable technique for identifying trigger points.
A pistoning action was used to deactivate trigger points until the muscle relaxed and then the needle was removed.
- Difficulty accepting this may cause pain
- Home exercises (thoracic extension and scapular stability)
- Difficulty accepting this will help symptoms
- Posture awareness reinforced by the application of kinesiology tape
- Patient X felt this was not necessary as she had good posture
- LI 4; LI 15; TE14; GB 21 Needles left in for 35 minutes.
- Patient calmer post-treatment. Felt more relaxed.
Bradnam (2003) suggests that when needles are stimulated and left in for 30-40 minutes, supraspinal levels of the CNS are affected.
The main aim of treatment 1 was to stimulate analgesic effects. Local dry needling was also completed to normalise sensory afferent input within the shoulder complex. Points used were LI4, LI 15, TE 14 and GB 21.
The patient reported she didn’t intend to return to Physiotherapy from the outset, however after her treatment, she felt a lot better. She was more inclined to co-operate with Physiotherapy. Overall she felt she was 20% better. Pain intensity remained between 1-6/10 but less frequent.
- Trapezius; IFS; SS
- Twitch response and referred pain with traps
- Referred pain with IFS
- Local pain with SS
- Manual pressure improves blood flow around trigger point areas. This helps.
- Thoracic spine mobilisations – Grade three, posterior to anterior glides over the thoracic spine. 3×30 per level
- Posture awareness reinforced by the application of kinesiology tape
- The patient reported she realised her posture was comprised (more than she was initially aware) and felt re-application of the tape would help her to improve her awareness
- SI 9; SI 10; SI 11;
- TE 10
- The patient felt relaxed and re-energised. Mood had improved
Patient X had experienced positive effects of acupuncture in treatment 1, she was more open to accepting her pain was ‘treatable’, therefore needling locally into the surrounding tissues would help to continue to normalise afferent input.
The remainder of the appointments were used to address predisposing factors to pain and facilitate return to work.
Patient X reported 60% better overall. She still got pain when driving long distances but not shorter ones. She hadn’t returned to gardening due to bad weather, but felt she could if she wanted to. She agreed to return to work with ‘lighter duties’. She could assist clinics and complete 1 scan every two hours (patient X felt she needed tape to provide feedback of posture when scanning to begin with).
Scapula stability exercises
- Able to control scapula movements when concentrating on exercises. Not automatic with spontaneous movement.
- Posture control in sitting.
- Patient X was aware she sat on her coccyx rather than ischial tuberosities. Correction of posture improved her thoracic extension.
- 80% better. Still on ‘light duties’. Keen to try increasing duties at work. Agreed to increase Sonography frequency to 50%.
- Kinesio-tape to increase posture awareness
- Increased awareness of scapula control when ultrasound scanning. Advised patient she needed to wean off this tape to ensure she did not become dependent on it.
- Education on trigger points and ischemic changes related to posture
- The patient had a better understanding and willingness to accept this as a cause of pain. The patient could identify this as her pain mechanism.
- 90% better overall
- Still not managing a full caseload at work, however, managing a 75% caseload. She is able to continue to self-manage.
- Her appointment was left open for one month. She did not return and was therefore discharged.
Acupuncture Points Used in Treatment One
This point was used on Patient X because she rated her pain constantly between 1–6 /10. This point has a very strong supraspinal effect on pain. LI 4 stimulates the descending pain suppression system reducing the amount of pain the patient experiences. This point has an effect for up to 16 hours (Wu et al., 2002).
Acupuncture points in muscles where the representation on the somatosensory cortex is particularly large (Hseich, 1997). Therefore, the hands and feet are strong analgesic points used to evoke supraspinal effects. Points include LI4, LU5, GB34, SP6, ST36, GB40 and LV3 as they increase activity of the hypothalamus (Wu et al., 2002). Only LI4 was used as other points were difficult to access due to the patient’s position.
This point also promotes Qi flow and discharges exogenous pathogens.
The large intestine meridian is a Yang meridian and has a powerful effect on analgesia, especially in the upper half of the body. This point is coupled with TE 14, it moves Qi and blood as well as facilitates joint movement. This point is also described as the anterior eye of the shoulder, therefore the point increases Qi flow, as well as moving Qi and blood. This point is also used to facilitate movement of her should joint.
The triple energiser meridian is responsible for smooth function between the three cavities of the body (upper, middle and lower). This point is indicated for heaviness in the shoulder and arm pain. This point is known as the posterior eye of the shoulder. It helps to dispel wind and cold which is associated with restrictions of Qi flow.
The Gall Bladder meridian is influential over muscle tension. The needle is inserted directly into the trapezius muscle belly, therefore this may provide a more local dry needling effect as well as facilitate Qi flow. It has a strong effect on depressing the shoulder, which is useful as patient X is very tense and presents with increased shoulder elevation. This is used for pain and stiffness in the back, neck and shoulders. It helps if someone has difficulty raising their arm.
Non specifically, acupuncture can modulate the excitability of emotional processing in the limbic and frontal regions, by normalising afferent input, emotional responses and the cortical awareness of emotional responses (Bradnam, 2011). Therefore all points used had a common goal of normalising the output from the brainstem to help alter the pain perception advanced by emotion (Nadapow et al., 2009; and Bradnam, 2011).
Acupuncture Points Used in Treatment Two
This point is used for shoulder, arm and scapula pain. A needle is inserted into the axillary crease. This point is directly over subscapularis, serratus anterior and latissimus dorsi. These muscles insert onto, or around the humerus and have an effect on scapula rhythm (Brukner and Khan, 2007).
This point is used for weakness in the arm and for pain. A needle is inserted into the lateral end of the border of the scapula spine (over supraspinatus).
This point opens up the chest. This is useful as patient X presents with protracted shoulders and reduced thoracic extension. Opening up the chest would increase the mobility into these tight areas. It is good for scapula pain and shoulder heaviness. A needle is inserted into the infrascapular fossa.
Needling locally is thought to elicit supra spinal effects, and therefore give strong analgesic effects as well as normalise the afferent input. Using this point still includes the biopsychosocial effects of acupuncture with regards to the yellow and blue flags identified for this patient. This is a he-sea point. Qi at He-Sea points is at its strongest and deepest. Energy can be tapped and overall function is regulated. This point regulates Qi. It helps to elevate shoulder pain.
The points chosen for acupuncture involved needling directly into muscles that had palpable trigger points, acupuncture stimulation of myofascial ATP may produce greater activation of sensitised poly-modal-type receptors, resulting in greater pain relief (Itoh et al., 2007).
Interestingly, the Small Intestine Meridian is linked to digestion.
The Traditional Chinese Medicine approach to acupuncture would correlate the disturbance in Qi flow in the Small Intestine Meridian to Digestion disorders such as irritable bowel syndrome (IBS). Whilst this correlation did not guide treatment points, it is an interesting observation, as this patient suffered from IBS.