Treatment of Frozen Shoulder Using Chinese Medicine
Frozen shoulder is the commonly used term for adhesive capsulitis, named for thickening and contracture of the capsule, the connective tissue surrounding the bony structures of the shoulder joint. The disorder was originally known as shoulder periarthritis or periomarthritis, because the inflammation surrounds the shoulder joint, but those terms are no longer preferred. Frozen shoulder is usually painful, but stiffness and restriction in movement are the primary characteristics resulting from the capsule contracture and are often likened to the immobilization of freezing versus the loosening of thawing. The disorder primarily affects people past the age of 40, particularly women; certain diseases increase the incidence of frozen shoulder, especially diabetes and thyroid diseases. Injuries are a common cause of frozen shoulder; for therapeutic purposes this condition should be distinguished from other injuries causing shoulder stiffness and pain, such as a torn rotator cuff. Range of motion tests (or, if necessary, x-rays or scans) can reveal the site of injury.
Frozen shoulder will often resolve gradually without intervention, but this can take many months (up to three years). The pain associated with shoulder movement is often relieved by use of ordinary anti-inflammatory drugs; in severe cases, steroids may be used temporarily. Physical therapy, based on stretching or range-of-motion exercises for the shoulder may hasten the improvement considerably and are the current standard therapy. Chinese medical interventions, especially acupuncture, have been claimed to be helpful.
The first description of frozen shoulder was provided by the French physician E.S. Duplay in 1872. During the 20th century a corresponding Chinese term arose: "50-years shoulder" (wushi jian), referring to the typical age of onset of the disorder; the term frozen shoulder (jianning) is also used in China. While there are numerous references to traditional style Chinese medical treatments for problems of the shoulder area, investigations into the use of the therapies specifically aimed at frozen shoulder have only been described in the last few years.
One of the earliest Chinese reports of acupuncture treatment of frozen shoulder was published in 1991 (1), based on a simple treatment method. The author of the article, Zhang Maohai, claimed to have found an effective therapy through his experiences. He focused on one acupuncture point, yanglingquan (GB-34), located on the leg, which he said seemed more effective than treating multiple points. The point was needled on one side only, the same side as the affected shoulder. In rare cases where this same side treatment did not seem to be helpful, the point was needled on the other leg instead.
The technique used was deep insertion (2.0-2.5 cun), followed by rotating and thrusting to get the qi reaction; the reducing technique was used for all patients, but deficiency patients were administered the treatment with both reducing and reinforcing techniques. The needle was maneuvered again every 3-5 minutes to maintain the stimulus. In the meantime, the patient was advised to move the shoulder joint. Total needle retention time was about 30 minutes, and five daily sessions made one course of treatment. After two courses of treatment (with a break of a day or two between courses), the frequency of treatment was reduced to every other day until the condition was resolved to a satisfactory extent. In the event of acute shoulder pain, electrostimulation of the needles was used (intermittent waves, strong intensity).
It was claimed that as a result of this therapy, 64% of the 172 patients so treated were cured, and all the rest (except 8 patients) showed some degree of improvement. In two cases that were detailed, the total treatment involved 10 sessions in one case and 20 sessions in the second case.
The selection of this acupuncture point is of interest. Traditionally, yanglingquan is mainly indicated for treatment of lower limb disorders, such as pain and numbness in the legs and knees, but the effects of stimulating this point are thought to also extend upward along the gallbladder meridian, which traverses the costal region to the shoulder. There, the meridian passes through the point jianjing (GB-21), indicted for stiffness of the neck, pain of the shoulder and upper back, and for difficulty moving the arm. A further basis for using yanglingquan is its reputation for soothing and moistening the sinews. Since the shoulder capsule is contracted, this action is considered important to healing the disorder.
A report on uses of yanglingquan was provided by Lü Jingshan in 1993 (2). Treatment of this point was described as being valuable for pain of the shoulder, elbow, costal region, lower back, and knee. Regarding shoulder pain, Lü wrote:
Shoulder pain is most often due to periarthritis of shoulder or injury to soft tissues due to invasion of wind and cold, or damage to channels or tendons that obstruct passage of qi and blood and result in pain. Following the principle of 'malady above treated by selecting relevant acupoints below, the author treated pain in the shoulder by acupuncture at yanglingquan (GB-34) with fairly satisfactory results, particularly in cases of short duration or caused by contusion or sprain.
He described a treatment strategy similar to that outlined above, with 30 minute needle retention and stimulus at the beginning and then at intervals (but, in this case, 10 minute intervals), while the patient exercised the shoulders. Application of acupuncture to yanglingquan on the side opposite the affected shoulder was used by another group, who reported on several successful uses of contralateral therapy (3).
A similar method was described in a report by Feng Zhengen (4), using the extra point lingxia, located 2 cun below yanglingquan (GB-34). The point on the same side as the affected shoulder was needled, while sanjian (LI-3), on the hand, was needled on the opposite side. The patient would move the affected arm during the acupuncture therapy. Treatment was given daily for 10 sessions, followed by a 2 day break and then another 10 sessions. It was reported that of 210 patients treated, 158 cases were resolved, and that all but 12 cases showed some improvement. The selection of lingxia, rather than yanglingquan was based, according to the author, on the fact that he found a marked tender point at this spot which, when pressed, alleviated the shoulder pain.
A point in this same area of the leg was selected for treatment of frozen shoulder by K.O. Sun and his colleagues in Hong Kong (5). They chose zhongping, an extra point located 1 cun below zusanli (ST-36). Deep needling (2.5 cun) was used with stimulus to get deqi, with additional stimulation every 5-6 minutes, and total retention time of 20 minutes; this treatment was administered twice per week for six weeks. The study was somewhat small, with 22 patients in a control group doing only the recommended shoulder range of motion exercises, and 13 patients doing exercise plus getting acupuncture. Both groups showed improvement, with a significant advantage to the acupuncture group.
Another acupuncture point in this same area of the leg that is used for shoulder disorders is tiaokou (ST-38). It is especially considered for treating acute shoulder pain, and is stimulated while the patient moves the shoulder. Jorge Vas and Emilio Perea-Milla compared the effects of needling tiaokou on shoulder pain when the treatment either did or did not elicit deqi, finding that deqi was important to gaining the desired prompt alleviation of pain (6). The successful use of tiaokou for frozen shoulder had been mentioned in an early publication by German acupuncturists (7).
The points chosen to treat frozen shoulder are often selected from those on the small intestine meridian, especially from SI-9 through SI-12, which run across the shoulder area. A key point is bingfeng (SI-12) at the attachment zone for the shoulder capsule. Bingfeng (grasping the wind; which became the title of a book about the names of acupuncture points; 8), is located by raising the arm, which produces an indentation at this spot. It is used to relieve disorders where there is shoulder pain accompanied by difficulty raising the arm, as occurs with frozen shoulder. In a report published in 1998 (9), results from treating 60 patients with "shoulder-arm" syndrome were relayed. Although this report did not address frozen shoulder, it claimed to produce marked effects through use of this single point (a second point would be treated for manifestations of the disorder in the forearm or hand).
Local treatment was the primary focus of a recent report by Jin Dongxi and Li Zhingtai, who described treatment of 50 patients with frozen shoulder using acupuncture and massage (10). They stimulated several points on the shoulder, including bingfeng, as well as others on the hand and arm of the same side as the affected shoulder. The points selected for treatment were:
extra point taijian (the name means "lift shoulder;" it is located 1.5 below the anterior part of the acromion);
extra point jubi (the name means "raise arm;" located 3.5 cun below the anteroinferior part of the acromion);
tianzhong (SI-11); bingfeng (SI-12); and houxi (SI-3)
naohui (TB-13) and jianliao (TB-14)quchi (LI-11) and hegu (LI-4)
During each acupuncture session, 4-8 points were selected for treatment, with stimulation maintained by electro-acupuncture, relying on the highest stimulus tolerated by the patient (with a loose-dense alternating waveform). Manipulation of the arm so as to relax the tendons around the affects shoulder were also performed, as well as other arm movements and kneading of the muscles. It was reported that the condition resolved in 48 cases and that all other cases had some degree of improvement.
The elbow point quchi (LI-11) included in the above protocol is traditionally utilized for treating pain in the shoulder and arm, and it considered especially useful when the pain prevents the arm from being lifted. In 1999, an article by B.H. Ma (11) described use of three acupuncture points for frozen shoulder, recommending two points along side of quchi (LI-11; one cun anterior and one cun posterior to the point) plus jianyu (LI-15) located at the shoulder. This area (shoulder and upper arm) is to be treated by cupping about 15 minutes after the needling is done, followed by a massage therapy with rapid motion of the palm against the arm and then shaking of the arm by holding at the wrist and lifting the arm to 90 degrees, then shaking with a downward pressure.
A treatment method relying primarily on local points is presented in the Encyclopedia of Practical Traditional Chinese Medicine volume on acupuncture (12). The recommended points are mainly from three yang channels of the hand-arm-shoulder area: jianyu (LI-15), binao (LI-14), quchi (LI-11), and hegu (LI-4) of the large intestine meridian; jianzhen (SI-9) and houxi (SI-3) of the small intestine meridian, and waiguan (TB-5) of the triple burner meridian. In cases where the pain radiates to the neck and back, additional small intestine meridian points would be added, such as bingfeng (SI-12) and quyuan (SI-13). Combining acupuncture and moxibustion was also suggested, with moxibustion especially at jianyu (LI-15) for 20 minutes.
Treatments featuring both the local points (shoulder/arm) and distal points (leg) have also been described in the context of clinical reports. Emad Tukmachi, in England, wrote an article on treatment in the journal Acupuncture in Medicine describing his approach (13). This report was not about a controlled trial, but about treatment of a series of 31 patients. He asserted that treatment effect will usually be noted within about 6 sessions and that successful treatment may require from 4-19 sessions. In a summary of this report, he noted that:
Ashi or trigger points around the shoulder should be carefully sought and needled superficially; tiaokou (ST-38) with strong manipulation is useful. Deqi should be sought in the robust patient, with less stimulus in the weak patients. Electroacupuncture at quchi (LI-11), jianyu (LI-15), jianjing (GB-21), and jianzhen (SI-9) at 5 Hz helps; yanglingquan (GB-34) bilaterally for 2 minutes alone often controls pain and releases stiffness. Auricular therapy at shenmen, shoulder, shoulder joint, clavicle, and adrenal points is helpful. The patient should exercise faithfully with a slow warm-up.
Dr. Li Lingling offered data from her work with frozen shoulder, which is presented on a website (14), and involves the local and distal points, with points on the large intestine dominating the shoulder/arm selections. According to the report, 61 patients were treated using electro-acupuncture and massage. The main acupoints treated were jianyu (LI-15), jianzhen (SI-9), quchi (LI-11), binao (LI-14), and tiaokou (ST-38), and the primary supplemental points were jianliao (TB-13), shousanli (LI-10), houxi (SI-3), taiyuan (LU-9), and yinlingquan (GB-34). Treatment was set up with two groups of points for each patient, one group of five points treated one time, and another group of five points treated the next time. Massage therapy included massaging various muscles and certain acupuncture points in the shoulder area. After about five treatments it was reported that 25 of the patients had the problem resolved and that all but three others showed some degree of improvement.
Finally, the use of scalp acupuncture should be mentioned. This treatment is frequently used for chronic pain syndromes and was the subject of an evaluation involving 210 cases (15). A point was treated along the vertex-temporal line, which runs from the head vertex baihui (GV-21) to the temple at xuanji (GB-6), about 40% of the way from the vertex to GB-6, which is in the zone corresponding to upper extremity disorders. The needle was threaded about 30 mm (about an inch) towards the temple (a second needle, inserted close to the same point but angled 45 degrees to the first and crossing its path, was often used to get more intense stimulus). If only one shoulder was affected, the contralateral side would be treated; with both shoulders affected, both sides would be treated. The patient was advised to relax, focus on the affected shoulder, and carry out shoulder movements during the treatment, while the practitioners manipulated the needles (with repetitive rapid withdrawal about 3 mm, then slower return) at least every 5 minutes and sometimes also massaged the shoulder. The needles would then be retained for 1-2 hours, or up to 1-2 days for severe cases. Typically, treatment was carried out every 1-2 days with seven sessions as a course of treatment. It was claimed that on the basis of this therapy, 72% of the cases were resolved after one course of treatment, and that all but 3 of the patients showed some degree of improvement; the first 3-5 sessions of scalp acupuncture were said to often bring significant relief.
As is often noted for treatment of acupuncture therapy, the methods used for frozen shoulder involves diverse ideas about selection of points. There are two main strategies: involving either local or distal treatments. Many of the local points chosen are ones at the shoulder and then some others on the affected meridian (mainly small intestine and large intestine meridians) along the arms and hands. Distal points may be used instead (as in the case of several below the knee points, and also for scalp acupuncture). In some cases, contralateral treatment is relied upon; other times, both local and distal points are on the affected side. Less often, both local and distal points are used. In terms of the points most frequently selected, the local points jianyu (LI-15), bianao (LI-14), and quchi (LI-11) of the large intestine meridian and jianzhen (SI-9), bingfeng (SI-12), and houxi (SI-3) of the small intestine meridian are emphasized. The commonly used distal points are yanglingquan (GB-34) and tiaokou (ST-38) plus several extra points between or to either side of these points were each mentioned. Acupuncture therapy was supplemented by massage and/or the patient's own exercises in virtually every case. Sometimes physician-managed manipulations would be used (see illustration, below).
Pain in the upper body is often deemed a disorder related to invasion of wind, and a condition with stiffness is often associated with coldness, so frozen shoulder fits the ancient category of wind-cold invasion. Modern thinking on the subject of persisting pain at a fixed site suggests that blood stasis may also be involved.
A typical traditional formula considered suitable for "50-years shoulder" is Juanbi Tang, which has the wind dispelling herbs chiang-huo and siler and the blood vitalizing herbs turmeric, tang-kuei, and peony. These herbs are used in a base of tonification therapy that is suited especially to those who are elderly and suffer from a disorder in which there is easy invasion of wind and development of stagnation due to qi and blood deficiency. Hence, in addition to the blood nourishing herbs tang-kuei and peony, the qi tonic and center strengthening combination of astragalus, fresh ginger, jujube, and licorice is included.
An herbal preparation described on the internet (16) as a successful remedy for frozen shoulder has the following main herbs: chiang-huo, siler, tu-huo, cinnamon twig, chin-chiu, vitex, cnidium, millettia, and salvia. Here, cnidium, millettia, and salvia serve to vitalize blood and nourish blood, while the other herbs dispel wind and warm the meridians.