Acupuncture management for the acute frozen shoulder: A case report

Abstract After an acupuncture treatment 24 times, the symptoms are recovered right shoulder both active and passive full range of movement in all directions, and pain‐free. Furthermore, no adverse effects were observed.


| BACKGROUND
A 45-year-old male patient complained about the pain in the right shoulder and restriction of shoulder movement of active and passive motion with abduction and flexion for 5 days. Acupuncture at Zhongping, LI14, and Ashi points 24 times on his right shoulder successfully recovered the clinical symptoms.
Frozen shoulder is a common glenohumeral joint condition. The clinical guidelines describe the frozen shoulder as a painful complaint, combined with active and passive glenohumeral range of motion (ROM) restrictions, especially in the external rotation and abduction direction. 1 This symptom is related to underlying fibrotic processes at the capsuloligamentous structures. 2 It has been reported that its prevalence ranges from 2% to 5% of the general population, specifically in the age range of 40-60 years old. 3 The pain can be developed to severe, may cause pronounced sleep disturbance. Restriction of the range of motion is usually more marked with external rotation, but less prominent with the abduction and internal rotation. Although physiotherapy, analgesic, and anti-inflammatory medications, chiropractic techniques, and exercise therapy are commonly used, the efficacy is variable. 4 Literature reviews had been implemented in order to evaluation of effectiveness outcomes and painfree strength of acupuncture treatment, such as a clinical trial study of Ling Gao et al 5 ; they concluded the therapeutic effect of intensive moxibustion plus acupuncture is superior to that of simple acupuncture in improving symptoms of frozen shoulder in patients. In another controlled clinical trial study of Mahsa Asheghan et al 6 , they found out that acupuncture causes improvement of movements of the shoulder in the patients, active and inactive movements in flexion and abduction directions were significantly improved in the case of mentioned movements compared to the past. Therefore, the implementation of acupuncture can be considered as an approach to improve movements of the shoulder in frozen shoulder patients.

| CASE PRESENTATION
We report the case of a 45-year-old male university lecturer. The main symptoms of the patient with right shoulder pain, restriction of shoulder movement of both active and passive motion with abduction and flexion for 5 days. He complained of dull and achy pain in the right shoulder and with a sharp pain to the posterior right arm, a hard time computer typing work himself, and unable to do weight training. The patient was experienced similarly medical complain 1 year before and he took the analgesic and anti-inflammatory medications, after 5 days recovery. The main clinical findings include pain was aggravated by any movement of the right upper limb, lying on the right upper limb and he was awakened during sleep when he rolled onto the affected upper limb. The pain was slightly relieved by taking a hot gel pack on the right shoulder. The main diagnoses are his right glenohumeral joint active ranges of motion (ROM) were as follows: internal rotation 15°, extension rotation 10°, forward flexion 20°, extension 30°, and abduction 10°. The resisted right glenohumeral joint flexion, abduction, and internal and external rotations were graded 3/5. The right glenohumeral joint passive ROM was 5° more in each direction. Posterior and posteroinferior joint play of the right glenohumeral joint was restricted and painful.

| CLINICAL OUTCOME
The main outcomes are the patient underwent 3 weeks, the active right glenohumeral abduction, flexion, and external rotation were 35 (10), 60 (20), and 15 (10) degrees, where the passive abduction, flexion, and external rotation were 70, 80, and 20°, respectively. After underwent 6 weeks, the patient had pain-free and full range of motion (Table 1).

| DISCUSSION
Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by shoulder stiffness, pain, and limitation of both active and passive range of movement in all directions. 9 Lundberg suggested patients suffering F I G U R E 1 Location of Zhongping acupoint from frozen shoulder syndrome into "primary" and "secondary." Primary adhesive capsulitis pertains to those patients who present with no significant findings in the medical history, clinical examination, or medical imaging evaluation to explain their motion limitation and pain, and secondary with a known etiologic factors. 10 The main symptoms of a patient found usually indicate a gradual onset of shoulder stiffness and pain. The pain is aggravated by the shoulder joint movements, especially external rotation, and sleeping on the involved side, and is relieved by limiting the use of the extremity. 11 One of longterm follow-up analysis of a randomized controlled trial study of Park et al, 12 , the results showed that Bee venom acupuncture and physiotherapy remain clinically effective 1 year after treatment and may help improve longterm quality of life in patients with adhesive capsulitis of the shoulder. In addition, one of randomized controlled double-blinded studies of Sven Schröder et al 13 concluded that acupuncture has a specific impact on adhesive capsulitis beyond the placebo effects that may not only be beneficial in reducing short-term pain perception, however, may also have a positive clinical outcome for long-term influence of the time course of recovery. In this case report, we have used the acupoints are Zhongping, LI 14, and Ashi point. The strengths of the acupuncture management of this case and the implementation of acupuncture cause an improvement in movements of the shoulder in the patient suffering from frozen shoulder. After an acupuncture treatment 24 times, the symptoms are recovered right shoulder both active and passive full range of movement in all directions and pain-free. Furthermore, no adverse effects were observed. The outcomes in this case report are encouraging and supporting the effectiveness of acupuncture in the management of frozen shoulder. Further studies will needed to enroll large numbers of patients to inform evidence-based acupuncture practice.

ROM Abduction Flexion
External rotation T A B L E 1 Improvement of the active and passive range of motion (ROM) with acupuncture treatment