Name: Puneet Narula
Date of Course: 7-9 Jun/2-4 Aug
Venue: RAF High Wycombe
Word count: 2530
Complex case of chronic shoulder impingement with parasthesia : Manual acupuncture, an effective tool (A case report)
Abstract
This case study seeks to integrate clinical reasoning model of Western acupuncture with a traditional Chinese acupuncture paradigm for the clinical management of the complex case of shoulder impingement, parasthesia in all four limbs and menopause. Patient was given traditional physiotherapy along with manual acupuncture, which helped in significant reduction in pain (NPRS – 0/10) and improving range of movement at the end of treatment sessions along with other subjective markers mentioned below.
Keywords: Acupuncture; Shoulder pain; Clinical reasoning; shoulder impingement and menopause.
Introduction about condition (s): This case report is a complex case of two conditions (Shoulder Impingement Syndrome (SIS) and menopause) leading to a very distressed and disturbed patient. Firstly, SIS is defined followed by menopause.
Shoulder impingement syndrome (SIS) is one of the most common diagnoses of patients with shoulder problems. Patients with this syndrome experience pain in the deltoid muscle area, especially during arm elevation. The rate of SIS was 44% and was the most frequently recorded disorder. Treatment of SIS always starts conservatively. A broad spectrum of conservative treatments for SIS is available in primary health care: rest, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, physical therapy, and manual therapy (Dorrestijn et al., 2009). Patients with SIS are often operated on when conservative treatments fail. However, in a recent systematic review (Dorrestijn et al., 2009) it was shown that no conclusion could be made about whether surgery is better than conservative treatment.
The secretion of the ovarian hormones oestrogen and progesterone decreases when a woman is around 50 years old, and eventually menstruation stops. This period in life is called the menopause (Nelson, 2008). Vasomotor episodes with hot flushes and night sweating are the most prevalent complaints related to menopause. A hot flush is described as a feeling of intense heat in the face, neck and chest. Other symptoms related to the menopause are disturbed sleep, anxiety and depression, somatic symptoms, reduced memory and concentration, urinary incontinence and sexual problems (Borud et al., 2010).
Introduction about case
For the purpose of this study the patient will be referred to as Mrs. X, who was a 50 yrs. old housewife, and was referred to physiotherapy with a diagnosis of right shoulder impingement, with 2 years history of gradual onset of symptoms, progressively worsening for the last 9-10/12. She was injected with a cortico-steroid injection 6/12 ago with no success. On subjective assessment she described her symptoms as constant deep, dull, and throbbing pain (NPRS – 5-9/10) in the right shoulder which got worse with over head movements and sudden movements of right shoulder. She also reported P+N along with numbness in right arm, forearm and fingers (all). On further questioning about 24 hours pattern, she reported P+N and numbness in all 4 limbs, worse in right upper limb, when she goes to bed. During assessment she looked depressed, sounded very disturbed and anxious. She was otherwise medically fit with good appetite and no red flags. During past 1 year she had her blood tests, Ultrasound scan for shoulder, MRI Cervical Spine/ shoulder done. Figure 1 below shows and explains symptoms briefly on a body chart, followed by table 1 & 2 which briefly explains subjective and objective examination.
Fig 1: Body chart explaining symptoms
Subjective assessment:
| Aggravating factors | Overhead movements (instantly), carrying shopping bags |
| Easing factors | Nothing |
| Severity | High |
| Irritability | Moderate |
| Nature | Mechanical + inflammatory nociceptive/ peripheral neurogenic/ affective pain mechanisms. |
| 24 Hours pattern | AM- constant pain, PM- worsens with activities, Night- very disturbed, can’t sleep more than 1.5 -2 hrs. Night sweats present. |
| Past Medical History | Menopause for last 14 months |
| Drug History | Sleeping medication, anti-depressants, Co-codamol, Paracetamol, Diclofenac and Tramadol. NO HELP |
| Investigations | Subacromial bursitis (R) on US scan 8/12 ago. |
| Social History | Housewife, goes to gym and swimming 1-2/week, right handed. |
| NPRS | Constant 5-9/10 |
| GOALS | Reduce pain & improve function of right shoulder, reduce anxiety and improve sleep pattern. |
Table 1: Subjective assessment, contents above marked with yellow are subjective markers.
Objective assessment: Day 1
| Observation | Stoop posture, low mood, tired looks, (R) shoulder girdle higher than (L) and Protruded chin (mild). |
| On Examination
C. Spine (AROM) |
Near full, pulls in end range (of flexion, Left side and right side flexion). |
| R GHJ (AROM) | Flexion – 70˚(P1), Abduction – 70˚(P1), HBB – L SIJ (P1), HBN – L ear (P1) |
| R GHJ (PROM) | Flexion – Full, pulls EOR, Abduction – Full, pulls EOR, HBB – T12, HBN – occiput, pulls EOR |
| L GHJ (AROM) with OP | Full and pain free |
| Neural exam | Myotomes: R = L
Dermatomes: R=L Reflexes: R=L Neurodynamics: Median Nerve bias B/L, R > L |
| Palpation | Increased tension in B/L upper Trapezius, Tender Teres Minor (R) lateral attachment |
| PAIVMS Cx Spine | Mild tenderness present C1 – C7 |
| PAIVMS/ PPIVMS Tx Spine | Reduced movement @ Mid Tx Spine (T4- T8) |
| Special Tests | Positive Hawkins Kennedy and Empty Can test |
Table 2: Objective assessment, contents above marked with yellow are objective markers.
Analysis/ Impression: The above findings seem to be consistent with R Shoulder impingement with reduced Median nerve mobility along with Menopausal symptoms and parasthesia.
Pain Mechanisms: After analysing the information from the above findings the following pain mechanisms were anticipated, which is considered to be the most important part of the puzzle.
The chief complaint was right shoulder pain worse with movements which would be a mechanical nociceptive pain mechanism. Her pain was constant which would mean continuous irritation or inflammatory component too. Peripheral neurogenic mechanism comes into picture because the pain radiates down the right arm, plus there was a median nerve bias. The paraesthesia symptoms are a bit unusual here, which could either be because of abnormal processing or hormonal factors. Over all it was a very complex picture.
| Day 1 | Assessment plus mini Rx – Thoracic manipulation, home exercises given to maintain thoracic mobility. NPRS – 5-9/10 |
| Day 2 (1/52 later) | No change reported. Rx – Median nerve mobilisations done, self mobilisations advised as a home exercise + Deep tissue mobilisations for upper trapezius and teres minor done + Rotator cuff strengthening with yellow theraband explained and given as a home programme. Improved AROM (R) GHJ post Rx. F – 90˚, Abd. – 90˚ |
| Day 3
(1/52 later) |
Reports slight improvement for few hours post Rx. Same as before now. Continued with same Rx as before (Day 2). Reviewed the home exs. Doing them correctly. Advised to carry on with same exs. NPRS – 5-8/10. Advised to see GP for sleep medicines. |
| Day 4
(1/52 later) |
Reports no further improvement; however the effect of Rx lasted for 24 hrs. NPRS was 5-6/10 but is 5-8/10. AROM (R) GHJ, F – 75˚, Abd.- 75˚. Carried out with same Rx as Day 3. Able to do more exercises now. Sleep no change. Leaflet explaining acupuncture indications & contraindications was given to the patient. |
| Day 5
(1/52 later) |
NPRS 5-8/10. No further improvement reported. Sleep 1.5 – 2 hrs. Parasthesia no change. Acupuncture Rx started. Informed consent gained. Advised to continue with same exercises. |
| Day 6 (1/52 later) | NPRS 3-6/10. Sleep 4 hrs. continuous for 3 days post Rx. Parasthesia only in R upper limb. Continued with same Rx. Reports more strength in R shoulder. Exercises less painful. Advised to continue with same exercises. |
| Day 7
(4/7 later) |
NPRS 2-4/10. Sleep 4-5 hrs., every night since Rx. AROM (R) GHJ: F – 100˚, Abd. – 100˚. Parasthesia only in R upper limb. New acupuncture points introduced as a progression and to help menopausal symptoms. Advised to continue with same exercises. |
| Day 8 (5/7 later) | NPRS 1-2/10. Sleep 7-8 hrs. No parasthesia. AROM (R) GHJ: F – 110˚, Abd.- 110˚. New points added as a progression towards the joint. Advised to continue with same exercises. |
| Day 9 (1/52 later) | NPRS 0-1/10. Sleep 7-9 hrs. No parasthesia. Hawkins Kennedy and Empty can test negative. AROM (R) GHJ: F – 165˚, Abd.- 165˚,HBB – T12, HBN – occiput. Started going to swimming. Rotator cuff exercises progressed at 45˚ angle of shoulder abduction. Acupuncture continued as before (Day 8). |
| Day 10 (2/52 later) | Reports no issues. Much improved. NPRS 0/10. Sleep 7-9 hrs. No parasthesia. AROM (R) GHJ: F – 170˚, Abd.- 170˚,HBB – T12, HBN – occiput. Acupuncture continued as day 9. Advised to continue with same exercises. Happy to self manage. Put on SOS d/c (5/52). |
Table 3: Treatment protocol
Outcome measures were active range of movement of right shoulder measured with a manual goniometer in standing position each time for standardisation. Subjective pain and difficulty during shoulder movements like forward flexion, abduction, hand behind back and hand behind neck were measured on a 0-10 numeric pain rate scale (NPRS), (0: no pain/ effort and 10: maximum pain/ effort). Table 3 (above) summarizes the outcome measures/ scores noted from the first to the last session. Totally 10 treatments were administered; manual therapy techniques and exercises were used in the first 4 sessions, acupuncture in the fifth, and the exercises were continued as a home programme. After the completion of the treatment Mrs. X reported no issues with pain, paraesthesia, menopausal symptoms and better sleep at night. There were no adverse effects noted and reported by Mrs. X.
Clinical reasoning
This section discusses about the justification of treatment selection and progression with focus on acupuncture. The first four treatments consisted of a ‘hands on’ approach. Firstly, because it is evidence based and the patient could tolerate all manual techniques with a slight improvement in pain and movement and secondly, because the author did have no knowledge and skill to use acupuncture. In order to address the mechanical nociceptive component of pain, a number of manual techniques were employed together with rotator cuff strengthening exercises. She was also given self neurodynamic mobilisation exercises to address right median nerve bias. She was advised to do home exercises as tolerated with gradual progression.
On reflection of this case after 4 sessions it was decided to introduce Acupuncture. Acupuncture is emerging as one of the popular choices of treatment for musculoskeletal conditions e.g. shoulder impingement and other medical conditions e.g. Menopause. More recently, the understanding of acupuncture involves a rigorous, evidence based approach called Western medical acupuncture (White 2009). Western acupuncture involves the knowledge of neuro-anatomy to locate the various acupuncture points lying along the various meridians for the treatment of various conditions (Bradnam, 2007).
Management of specific category of pain in treating various musculoskeletal conditions by acupuncture will have more favourable outcomes than treating with a generic approach (Hall and Elvey, 2004) Various types of pains are treated by acupuncture and have almost similar effects but choosing a predominant pain mechanism will assist in decision making and progress of the patient (Bradnam, 2007; Lundeberg & Ekholm 2001).
Considering the predominant mechanical nociceptice pain mechanism with a component of inflammation, it was expected to achieve analgesic and anti-inflammatory effects from the acupuncture needle. As the patients symptoms were wide spread in general so it was decided to start distally. The distal points were selected as there was inflammatory component and local points might have proved to aggravate the symptoms (Lunderberg, 1998). The 4 points used initially (Day 5) were LI4 and LIV3 bilaterally as LI4 has strong analgesic effect (Hecker et al 1999), promotes QI flow and enhances opioid release with descending inhibition whereas LIV3 has supra spinal analgesic effect. These distal points were selected as they help the complex and chronic pain patients to get on board by calming down central nervous system. It also further helps the patient to sleep. These points were continued in the next treatment session (Day 6) as the patient reported improvement in pain and sleep pattern.
On Day 7, after quick assessment it was decided to address her menopausal symptoms and further improve her sleep pattern. So, H7 and KID6 were chosen bilaterally to address the disturbed sleep and hot flushes. However, menopause was not the reason of referral of this patient to physiotherapy outpatients. But it was decided to address menopause as this was keeping her awake during night. It is a well known fact that reduced sleep reduces the parasympathetic system activity which further means reduced healing and repair (Butler & Moseley, 2003).
On Day 8, patient reported no paraesthesia. So, adding H7 and KID 6 solved the complex part of the problem, abnormal processing or hormonal factors. The pain on NPRS was 1-2/10. So it was decided to progress further, closer to the shoulder joint. Anterior eye (LI15) and posterior eye (TE14) were chosen, mainly to regulate blood flow to carry away inflammatory exudates and improve ROM of right shoulder.
On Day 9, the pain pattern was changed from constant to intermittent ache. There was a significant increase in ROM noticed. Acupuncture points used on this day were same as the previous session. The shoulder exercises were reviewed and progressed. On Day 10, the patient reported no issues with pain, paraesthesia and sleep. Her ROM of right shoulder was nearly full. She had returned to swimming without much discomfort.
Patient was contacted after 6/52 over the telephone and reported no pain or parasthesia and a very sound night sleep. She also reported huge change in her life and health generally. She was still continuing with the exercises given to her on Day 10. She was therefore discharged as she was happy to self manage.
Acupuncture points & rationale :
| 1st a-Rx (Day 5) Aim: reduce pain and promote sleep |
Points LIV3 (B) and LI4 (B)
Rationale LIV3 & LI4: major analgesic points, calm CNS
| 2nd a-Rx (Day 6) Aim: reduce pain + maintain & promote sleep |
Points LIV3 (B) and LI4 (B)
Rationale LIV3 & LI4: major analgesic points, calm CNS
| 3rd a-Rx (Day 7) Aim: reduce pain + maintain & promote sleep + reduce menopausal symptoms |
Points LIV3 (B) + LI4 (B) + H7 (B) + KID 6 (B)
Rationale H7: calms brain, Sedation point; KID6: Regulates oestrogen & Progesterone
| 4th a-Rx (Day 8) Aim: reduce pain + maintain & promote sleep + reduce menopausal symptoms + increase shoulder ROM |
Points LIV3 (B) + LI4 (B) + H7 (B) + KID 6 (B) + LI15 (R) + TE14 (R)
Rationale LI15: Moves QI, blood + facilitate shoulder ROM
TE14: Dispels wind and cold, increases flow in channel & relaxes tendons
| 5th a-Rx (Day 9) Aim: reduce pain + maintain & promote sleep + reduce menopausal symptoms + increase shoulder ROM |
Points LIV3 (B) + LI4 (B) + H7 (B) + KID 6 (B) + LI15 (R) + TE14 (R)
Rationale LI15: Moves QI, blood + facilitate shoulder ROM
TE14: Dispels wind and cold, increases flow in channel & relaxes tendons
| 6th a-Rx (Day 10) Aim: reduce pain + maintain & promote sleep + reduce menopausal symptoms + increase shoulder ROM |
Points LIV3 (B) + LI4 (B) + H7 (B) + KID 6 (B) + LI15 (R) + TE14 (R)
Discussion: underlying mechanisms to treatment
This case study attempted to analyze and present the physiotherapy management of a patient complaining of shoulder pain with paraesthesia. Treatment was decided after taking into account the underlying pain mechanisms, the chronicity of the disorder, the relationship between presenting pain and menopausal symptoms.
There were many reasons for choosing Mrs. X for this case study. Firstly, this was author’s very first patient on which acupuncture was used as a tool. Secondly, it was decided to discharge Mrs. X and refer back to GP, in a peer review with a senior, as she was not showing significant improvement with manual therapy after 4 sessions. Thirdly, she had no contraindications for acupuncture. And finally, because this was the first time the author addressed menopausal symptoms, in so many years of practice.
Pain is considered to be attributed to poor movement flow of QI or its stagnation in a particular area of the body (Andersson, 1993). Acupuncture can provide pain relief through various mechanisms which have got strong clinical evidence and are being well researched (Jones, 1995; Bowsher, 1998; Cralson, 2002; Ma, 2004; and Pomeranz, 1996). Acupuncture mechanisms have been described at 3 levels mailny – peripheral, spinal and supraspinal (Lundberg, 1998). At the peripheral level, needling activates nociceptive afferents resulting in release of vaso-dilatory neuropeptides such as Calcitonin gene-related peptide (CGRP) and substance P, which modulates the immune response and assists in tissue healing (Sato et al., 2000; Weidner et al, 2000). Lundberg (1998) recommended needling to be close to the injured tissue with low intensity stimulation or gentle approach to encourage peripheral neuropeptide release. Care must be taken not to over-stimulate as it may release CGRP in more quantity which can have an opposite effect. In the periphery, CGRP has been shown usually to be pro-inflammatory (Brain, 1997), but in low doses it has a potent anti-inflammatory action (Raud et al., 1991). This justifies the use of local points LI15 and TE14 neurophysiologically in this case study.
Neurophysiologically, LI4 and LIV3 were thought to be the safest points to commence first time treatment by the author. Firstly, because manual acupuncture at LI4 and LIV3 points in healthy volunteers has shown to deactivate areas in the brain – prefrontal cortex and ACC – both of which take part in pain modulation (Yan et al., 2005). And, secondly because these points encourage Oxytocin release, which helps forget the memory of pain (Longbottom, 2010).
Finally, H7 and KID6 have been shown to be effective in a recent study (Nir et al., 2007) for menopausal symptoms, further recommended by Longbottom (2010), and being used in Traditional Chinese Medicine (TCM) for years. However, given the current lack of knowledge about the mechanisms of postmenopausal hot flushes (Sturdee, 2008), it would be unwise to speculate in detail on the possible mode of action of acupuncture (Borud et al., 2010).
Generally, during the treatment of acupuncture DE QI sensation has to be achieved to have a therapeutic effect, during which A delta afferent nerve fibres are activated which release inhibitory opioids like enkephalin in the dorsal horn where by blocking the descending pain signals at segmental level (Bowsher, 1998; Wang et al, 1985). This gives short term pain relief via pain gate control theory (Melzack & Wall, 1984). The other mechanism of analgesia by acupuncture is the activation of pathways from brain. This involves the release of endorphins which also act as mood enhancer (Pomeranz and Chui, 1976; Clements et al., 1980). These endorphins are released into cerebrospinal fluid via neuronal channels between PAG in brain stem (Takeshige et al, 1992) and hypothalamus inducing noxious inhibitory controls to give pain relief (Bradnam,2007).
All the above discussed points had a role to play in Mrs. X pain mechanisms and general well being. There is a great wealth of evidence available on various acupuncture mechanisms. However, the discussion on the treatment dose is very limited. In spite of all the neurophysiological evidences that has been the key to western acupuncture; it is still difficult to understand long term effects of acupuncture.
Conclusion
In conclusion, the integration of acupuncture along with physiotherapy in case of Mrs. X showed good results e.g. pain relief and improved shoulder movements. The extent of effects of acupuncture alone in relieving pain were difficult to determine as it was given in conjunction with other physiotherapy treatments e.g. joint mobilisations, Deep tissue mobilisation & strengthening exercises. However, acupuncture was certainly an effective tool as it improved patient’s sleep pattern, menopausal symptoms and paraesthesia. This possibly encouraged the patient to progress sooner with strengthening exercises which she found quite difficult in the beginning until Day 4.
Limitations
There were limitations recognized by the author, which included not having the knowledge and skill of administering acupuncture in the beginning of the treatment sessions with Mrs. X, which possibly would have saved some time and treatment sessions for the patient and NHS Trust. The other limitation was that the author did not explore any trigger points in the scapular region, perhaps because this was the author’s first patient, acupuncture was applied on.
Acknowledgements
I would like to acknowledge my gratitude to Mrs. X for her compliance and Mrs. Jennie Longbottom who trained me with the basics of Acupuncture along with clinical reasoning.
References
Andersson, S. (1993) ‘The Functional Background in Acupuncture Effects’. Scand J Rehab med 29, 31 – 60
Bradnam, L. (2007) ‘A proposed clinical reasoning model for western acupuncture’. Journal of Acupuncture association of chartered physiotherapists 21-30
Brain, S. (1997) ‘Sensory neuropeptides: their role in inflammation and wound healing’. Immunopharmacology 37, 133– 152
Butler, D. and Moseley, L. (2003) Explain Pain.
Clement, L., Loughlin, M., & Tomlin, S. (1980) ‘Increased beta endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain’. Lancet 2, 946-949
Carlson, C. (2002) ‘Acupuncture mechanism for clinically relevant long term effects reconsideration and a hypothesis’. Acupuncture in Medicine 20 (2-3), 82-99
Dorrestijn, O., Stevens, M., Winters, J., van der Meer, K., and Diercks, R. (2009) ‘Conservative or surgical treatment for subacromial impingement syndrome? A systematic review’. J Shoulder Elbow Surg 18, 652-660
Hecker, H., Steveling, A., Peuker, E., Kastner, J., Liebchen, K. (1999) ‘Colour Atlas of Acupuncture, Body points, Ear points, Trigger points’. Thieme, Stuttgart
Jones, M. (1995) ‘Clinical Reasoning and Pain’. Manual Therapy 1, 17-24
Longbottom, J. (2010), ‘AACP approved foundation course – acupuncture for pain relief’. ALIED, RAF High Wycombe
Lundeberg, T. (1998) ‘The physiological basis of acupuncture’. Paper presented at the MANZ /PAANZ Annual Conference, Christchurch, New Zealand. August
Lundeberg, T., and Ekholm, J. (2001) ‘Pain –from periphery to brain’. Journal of the Acupuncture Association of Chartered Physiotherapist, February, 13-19
Ma, S. (2004) ‘Neurobiology of Acupuncture’. Evidence Based Complimentary Medicine, 1((1), 41-47
Melzack, R. and Wall, P. (1984) ‘Acupuncture and Transcutaneous Nerve Stimulation’. Postgraduate Medical Journal, 60 (710), 893-896
Nelson, H. (2008) ‘Menopause’. Lancet 371, 760–770
Nir, Y., Huang, M., Schnyer, R., Chen, B., and Manber, R. (2007) ‘Acupuncture for postmenopausal hot flushes’. Maturitas 56, 383–395
Pomeranz, B. (1996) ‘Scientific Research into acupuncture for the relief of pain’. Journal of Alternative and Complimentary Medicine 2, 53-60
Pomeranz, B., and Chui, D. (1976) ‘Naloxone blocks acupuncture an causes hyperalgesia: endorphin is implicated’. Life Science, 19,1757-1762
Raud, J., Lundeberg, T., Jansen, G., Theodorsson, E., and Hedqvist, P. (1991) ‘Potent anti-inflammatory action of calcitonin gene-related peptide’. Biochem. Biophys. Res. Commun. 180, 1419– 1435
Sato, A., Sato, Y., Shimura, M., and Uchida, S. (2000) ‘Calcitonin gene-related peptide produces skeletal muscle vasodilatation following antidromic stimulation of unmyelinated afferents in the dorsal roots in rats’. Neuroscience Letter 283, 137-140
Sturdee, D. (2008) ‘The menopausal hot flush—anything new?’. Maturitas 60, 42–49
Tekshige, C., Sato, T., Mera, T., Hisamitsu, T., and Fang, J. (1992) ‘Descending pain inhibitory system involved in acupuncture analgesia’. Brain Research Bulletin 29, 617-634
Weidner, C., Klede, M., Rukwied, R., Lischetzki, G., Neisius, U., Skov, P., Peterson, L., Schmelz, M. (2000) ‘Acute effects of substance P and calcitonin gene-related peptide in human skin – a microdialysis study’. Journal of Investigative Dermatology 115, 1015-1020
White, A., Grimsgaard, S., and Borud, E. (2010) ‘Menopausal problems and acupuncture’. Autonomic Neuroscience
White, A. (2009) ‘Western medical acupuncture: a definition’. Acupunct Med 27(1),33–35
Yan, B., Li, K., Xu, J., Wang, W., Li, K., Liu, H., Shan, B., and Tang, X. (2005) ‘Acupoint-specific fMRI patterns in human brain’. Neuroscience Letters 383, 236-240
