Medscape Clinical Essentials recently published an article called Thawing A Frozen Shoulder. Lots of treatment ideas were presented, from surgery to physical therapy, but absolutely no mention of using acupuncture or dry needling as a treatment option.

Acupuncture Canada faculty member Irene Biemann, PT, CAFCI, corrects their oversight. In her article, following, Irene considers treatment options from an anatomical acupuncture framework, as well as making use of Classical Acupuncture techniques. She’s had great success using a combination of approaches. What approaches do you use?

Thawing a Frozen Shoulder… with acupuncture

Physiotherapists and Chiropractors trained in acupuncture have the unique ability to use both their physical approaches, passive stretching, active exercise, modalities as well as applying many techniques of acupuncture to reduce pain and inflammation, rebalance the autonomic nervous system and restore function to a frozen shoulder.

I am going to outline a number of different acupuncture approaches that can be used in the treatment of “frozen shoulder” or adhesive capsulitis, including Complex Regional Pain Syndrome (formerly known as Reflex Sympathetic Dystrophy or Shoulder-hand syndrome). We can use both an anatomical acupuncture framework, as well as make use of Classical Acupuncture theory and techniques.

The acute phase, where there is severe pain and restricted movement is recognized by students of Acupuncture Canada (AC) as a “mad dog”. This concept, originally taught by Dr Joseph Wong referred to a situation where there is dysregulation of sympathetic function: severe pain, inflammation etc. where you want to avoid local needling as this will result in an exacerbation of symptoms.

There are various ways that treating distally from the shoulder can be done.

Autonomic Rebalance: As originally devised by Dr. Wong, we can use so-called sympathetic switches to lower sympathetic tone. GV26 should be used first, with gentle stimulation, pain should begin to recede within minutes. LI4, LR 3 and ST36 are also powerful sympathetic points that can be used.

Anatomical approach: The shoulder is covered by the Large Intestine (LI/Hand Yang Ming), Small Intestine (SI/Hand Tai Yang) and Triple Energizer (TE/Hand Shou Yang) channels. We can use distal points on these meridians such as SI3, SI6, TE3 or LI4, LI10.

Other points to consider as severity of pain is reduced are those points that are relevant to the shoulder’s nerve supply: C5 nerve root, Brachial plexus and the circumflex nerve. Needling Cervical Spinal nerve point C5, LU2 for brachial plexus, HT1 for Brachial plexus can be helpful.
The circumflex nerve can be stimulated by SI9, LI15 and TE14.

Empirically, ST 38 has been used as a useful distal point for shoulder problems.

As the patient progresses, you could also apply the one needle at a time technique for anatomically relevant points. This involves inserting a needle for a minute or so with gentle stimulation, removing it and assessing if there has been any change. One can treat the same point several times in this manner and get a cumulative effect.

Classical acupuncture approaches:

Xi-Cleft Points

Xi-Cleft points are a category of acupuncture points located distally on all the regular meridians and are considered to be points where Qi and Blood converge. According to Classical Acupuncture principles, pain is considered to be due to a blockage of QI and Blood, using Xi-Cleft points is indicated for severe pain. In the shoulder the points are, LI7, SI6 and TE7 and are chosen based on the location of the pain. Gentle active ROM exercises can be done with these needles in place.
Several years ago, I had a client (who responded extremely well to acupuncture) come in with a sudden onset of shoulder pain with no mechanical cause. I used these points and her pain was completely gone with just the one treatment and only those 3 points.

Tendino-Muscular Meridians (TMMs)

TMMs are very useful for treating pain. These meridians are the superficial layer enveloping the skin, muscles, tendons, joints and fascia overlying the deeper regular meridians and are implicated in most musculoskeletal problems. They are extremely useful for treating severe, acute pain (although I have also used them in acute flareups of chronic conditions, the key factor is the severity of pain). As with the Xi-Cleft points, you would choose the relevant meridian, e.g. LI for pain over the anterior aspect of the shoulder and then use the Jing-Well point, Tonification point and crossing point (all same polarity/limb meridians cross either on the head or the trunk). In the case of LI, the points are LI 1, LI 11 and the crossing point is GB 13 or ST8 depending on the reference used. Insertion is kept very superficial as these meridians are superficial, pain relief is also very rapid, usually within minutes. Additional relevant points on the painful meridian may be added as tolerated but only 2-3 at most. LI10 would be a good addition, again because of Blood and Qi.

Chinese Scalp Acupuncture

Developed in the 1950s this approach is based on functional areas of the brain. Rather than specific “points,” lines are used and needles are inserted tangentially along the relevant line for 30-40 mm depending on the location. The lines overlie specific parts of the cortex. Two of the most common areas I use for treating both neurological problems and pain are the Sensory Area that overlies the primary sensory cortex and the Motor area that overlies the primary motor cortex. Specific location is based on the homunculus that is attributed to those areas. Shoulder pain and mobility issues can both be treated using these lines on the opposite side from the affected shoulder. Needles are inserted and then manually stimulated. Pain reduction and improved movement can occur almost instantaneously in my experience. Exercises can easily be done with scalp needles in place.

Yuan Qi Acupuncture

This is an ancient system developed by Dr. Huatuo (He also developed the Huatuojiaji points) and passed down through time through different teachers. I learned this system from Dr. Suzanne Robidoux. It is an energetic system based on manipulation of the Yuan QI circulating in the body. As I mentioned earlier, pain is a blockage in the circulation of blood and energy, this system uses points on the opposite extremity on a paired yin/yang meridian and point selection is based on the location of pain that is related to 5 Elements theory (not the 5 Shu Points!). According to this technique, the shoulder is in the “wood element” so if the pain/dysfunction was in the LI Hand Yang Ming channel, the Wood point on the paired LR Foot Jueyin channel would be needled to unblock the circuit and re-establish circulation of qi and blood. The needling technique is rather uncomfortable but works extremely well and very quickly if your point selection is accurate.

What about Dry Needling?

Dry needling can be very effective in releasing tight muscles and improving function and mobility. However, as it is a local technique, one must use caution not to provoke more pain if the issue is too acute.

As you can see there are many different ways to approach the treatment of a “frozen shoulder” using acupuncture. At this point in my work, I would use a combination of approaches, depending on the patient. As I have had such great success using Chinese Scalp Acupuncture, I would likely start with that along with GV 26 if pain is severe, increasing passive/assisted movement and active movement as tolerated. If one channel/meridian were more affected, I would likely add in TMMs for that meridian. Having all these techniques at your fingertips turns treatment into an art: choosing the best approach for each individual becomes intuitive, creative and enjoyable to the practitioner as well as being highly effective for your patient.

By Irene Biemann, PT, CAFCI