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80

70
60
50
40
30
20Exercise plus acupuncture group
Exercise group
-5 0 5 10 15 20 25
Time (weeksAcupuncture for frozen
shoulder
appropriate treatment. In 1992, Shaffer et al9 reported a
long-term follow-up of idiopathic frozen shoulder. The
authors subecti!el" and obecti!el" e!aluated #2
patients who had been treated non-operati!el", at
between 2 "ears and 2 months to 11 "ears and 9 months
follow-up. The" found that $%& of patients still
complained of either mild pain, stiffness, or both mild
pain and stiffness of the shoulder, while #%& still
showed some restriction of mo!ement
.Fig 4. Constant Shoulder Assessment scores for
patients receiving treatment for frozen shoulder
The percentage of 'SA impro!ement from baseline
for each patient was computed and a summar" is
shown in Table (. At #-wee) assessment, there was a
*#.+& and a (9.,& impro!ement in shoulder function
for the e-ercise plus acupuncture group and the
e-ercise group, respecti!el". These relati!e
impro!ements were sustained at the 2%-wee)
reassessment .**.2& and +%.(& for the e-ercise plus
acupuncture and e-ercise groups, respecti!el"/.
'ompared with the e-ercise group, the e-ercise plus
acupuncture group was significantl" better after
treatment at # wee)s and on follow-up at 2% wee)s
.01%.%+, and 01%.%2$, respecti!el"/.
The anal"ses were repeated when all missing !alues
were discarded. All conclusions were essentiall"
identical with the e-ception of a significant difference in
mean 'SA scores now seen between the two groups at #
wee)s .01%.%21/. 2inal conclusions were drawn,
howe!er, from the intention-to-treat anal"sis.
Discussion
'lassicall" the s"mptoms of primar" frozen shoulder
ha!e been di!ided into three phases3 .1/ the painful
freezing phase4 .2/ the stiffening frozen phase4 and .(/
the reco!er" thawing phase. In the initial painful phase,
there is a gradual onset of diffuse shoulder pain lasting
from wee)s to months. It ma" ta)e up to 2 "ears or
longer for the patholog" to resol!e. Although
spontaneous reco!er" of frozen shoulder ma" ta)e
place within 2 "ears of onset without an" form of
treatment, man" do not impro!e withoutThe aim of this
stud" was to determine if acupuncture is an effecti!e
and safe treatment option that can enhance the speed
and degree of reco!er" of idiopathic frozen shoulder.
5-clusion criteria eliminated conditions mimic)ing
frozen shoulder or causing se!ere secondar" frozen
shoulder, while inclusion criteria limited patient
selection to those in the relati!el" earl" phase of the
disease, with appreciable restriction of motion and
pain. Shoulder pain for at least 1 month and less than
12 months67 duration was a criterion for the stud" to
determine whether acupuncture treatment could
enhance the speed of reco!er". The ris)s associated
with acupuncture treatment are generall" !er" minimal
.such as infection and haematoma/, and the rate of
occurrence is !er" low. Acupuncture also has high
patient acceptance in preference to other methods of
treatment. In this stud", there was no acupuncture-
related complication and onl" one patient in the
e-ercise plus acupuncture group discontinued
treatment due to fear of needle pain.
8ansen+( reported that $-minute acupuncture treatment
sessions were e9uall" as effecti!e for nec) and
shoulder pain when compared with 2%-minute sessions.
8owe!er, there was an imbalance between the groups
studied in terms of the pretreatment !isual analogue
score, and this combined with the limited trial size
suggests these results ma" not be reliable.
'onse9uentl", this stud" utilised the standard 2%minute
treatment regimen.
+1The 'SA was used for e!aluation of progress
following treatment.+1 This assessment is a simple
clinical tool that combines functional assessment of the
shoulder with assessment of indi!idual parameters,
such as pain and dail" acti!it". It therefore allows
e!aluation of progress after inur", treatment, or disease
with respect to these indi!idual parameters or in terms
of o!erall function. The 'SA is eas" to use, ta)ing onl"
a few minutes to perform. It is reliable and !alid in the
o!erall assessment of shoulder function, with low inter-
obser!er and intra-obser!er error rates.+1,++
There are, howe!er, two limitations of the 'SA. ++
2irstl", assessment of power is error-prone as accurat
e8:;< =ol * >o + ?ecember 2%%1 (,*
(!"-
stan#
ar#
error
$ean
%onst
ant
&'oul
#er
(sse
ssme
nt
score
Sun et al
measurement of power is difficult to achie!e.
Shoulder mo!ement is comple- and
conse9uentl" measurement of power in a single
arc of shoulder mo!ement is unli)el" to be
representati!e of full functional potential.
Secondl", in cases of shoulder instabilit", such
as oint dislocation, 'SA fails to reflect
accuratel" the true le!el of disabilit" incurred
and thus is a not a reliable outcome measure for
patients with complaints of instabilit". 2rozen
shoulder is characterised b" pain and limitation
of motion without fracture and dislocation.
<oint instabilit" and mar)ed power loss are
rarel" seen in patients with frozen shoulder and
thus, these limitations are not pertinent to the
stud" population. The 'onstant Shoulder
Assessment is, therefore, a good outcome
measure to e!aluate the se!erit", reco!er", and
treatment response of frozen shoulder.
Acupuncture treatment used in this clinical
trial was conducted according to the principles
of T';. Ancient 'hinese medicine considers
human health as facing the tensions created b"
opposing forces in nature6@the Ain and the
Aang. ;edical inter!ention carried out
according to this concept aims to restore
balance between the opposing energ" forces. A
concept of !ital energ" flow lin)ing circulation
to neurological function is fundamental to the
practice of acupuncture. The !ital life energ",
Bi, is thought to flow through a set of
interconnected channels, called meridians,
which follow a circadian rh"thm. The
meridians are interconnected b" Bi. 5ach
internal organ is thought to be associated with
a certain meridian, and the meridian is named
after the organ concerned. ?iseases and
discomforts, such as pain, are classified
according to the meridians the" in!ol!e,
whether the" ha!e a Ain .cold, h"pofunctional/
or Aang .hot, h"perfunctional/ nature, and
whether the flow of Bi is e-cessi!e or
deficient. According to T';, pain in the
shoulder is associated with wea)ness in the
6Cstomach67 and 6Cspleen67, and deficienc"
of Bi. 2rozen shoulder belongs to the group of
diseases characterised b" bloc)age of Bi, or to
the Di s"ndrome, that is, painful locomotor
disorders. The definition of Di in 'hinese
medicine is obstruction or interference with
the flow of Bi and blood. It is mainl" belie!ed
to be due to the deficienc" of Ain and to
inade9uate defence of the s)in against in!asion
b" the pathogenic factors of wind, cold, and
dampness into the bod". The resulting stasis of
Bi and blood in the channels leads to pain,
aching, and stiffness in the muscle, bones,
tendons, and oints.
'lassical acupuncture prescriptions for
frozen shoulder are designed6@b" selection of
local, distal, and tender .ashi/ points according
to the course of the meridians6@to rela- the
muscles, disperse pathogenic
(,, 8:;< =ol * >o + ?ecember 2%%1+$factors
such as e-cess wind, cold, and dampness,
remo!e obstruction in the affected meridians
and their collaterals, and to regulate the Bi
and blood. A combination of local and distal
classical 'hinese acupoints are commonl"
used for the treatment of frozen shoulder.(*,+#
ED (+ .Aangling9uan/, Focal points include ED
21 .ianing/, FI 1$ .ian"u/, FI 1+ .Dinao/, T5 1+
.ianliao/, and SI 9 .ianzhen/. ?istal points
utilised are FI + .hegu/, FI 11 .Buchi/, St (,
.Tiao)ou/,(9
and Ghongping.(#(# Ghongping is an e-tra
acupoint l"ing along the stomach meridian,
the so-called Aang ;ing ;eridian. It is
situated 1 cun below Gusanli .St (#/ and about
2 cun abo!e Shangu-u .St (*/, slightl"
lateral, on the medial side of the fibula .2ig 2/.
'un is the 'hinese proportional measure, and
1 cun is appro-imatel" 2.$ cm or the distance
between the pro-imal and distal
interphalangeal oints of the inde- finger of
the patient. The stomach meridian has its Bi
running across the shoulder. It is a Aang
meridian in balance with its Ain counterpart,
an imbalance of which can cause the Di
s"ndrome. Stimulation of the Ghongping
acupoint can impro!e the flow of Bi across
the shoulder. ;oreo!er, the scapulohumeral
region is the place where muscles con!erge,
and Ghongping is an influential point in
relation to the tendon. Acupuncture applied to
this acupoint can rela- the tendon and remo!e
obstruction in the meridians to relie!e pain.
'ontralateral needling, characterised b" the
contralateral selection of points is !er"
effecti!e in the treatment of shoulder pain.
The mechanism of action is possibl" the
stimulation of Shu points, and hence the
meridians and collaterals, on the health" side.
This, in turn, is thought to e-cite the meridians
and collaterals on the affected side, which
ha!e been in a state of stagnation of Bi and
blood, thus, to an e-tent, clearing and
acti!ating the meridians and collaterals, and
relie!ing pain. 0ractice has pro!ed that
needling of the Ghongping point and acti!e
mo!ement of the affected shoulder, if
performed simultaneousl", are particularl"
effecti!e in treating shoulder pain and
arthritis.+$ The mechanism of this s"nerg" is
not clear, but ma" be related to the facilitated
flow of Bi across the shoulder. >eedling
applied to the Ghongping acupoint to treat
frozen shoulder has the ad!antage of selection
of onl" one point, conse9uent ease of treatment
deli!er", and good therapeutic results. Hnli)e
local points and some distal points o!er the
upper limb .FI + and FI 11/, Ghongping is
distant from the painful site and will not
interfere with shoulder e-ercise and assessment
during the acupuncture treatment.
According to T';, if a part of the bod" is
not mo!ed, then the Bi will not circulate
through it, leading to stagnation. If this
occurs in the shoulder oint, th
e
oint becomes stiff and painful. 0h"sical
e-ercise is important in harmonising the bod"
.Ain/ and the spirit .Aang/, as well as the Bi,
helping to clear and acti!ate the meridians and
collaterals. This is essential for internal
harmon" between !arious organ s"stems, as
well as between the bod" and the natural
en!ironment. The impro!ement shown b" the
e-ercise group in this stud" can be e-plained
b" T'; in this wa".
The therapeutic effect of acupuncture
appears at its best when the patient has a
feeling of needle sensation .de 9i/. ?uring
6Cde 9i67, the underl"ing muscle appears to
grab the needle and hold it firml", and
propagation of one or more of these sensations
ma" occasionall" be felt along the meridian.
The sensation of 6Cde 9i67 must be
distinguished from pain or discomfort due to
poor needling techni9ue. In most classical
practice, the acupuncturist does not remo!e the
needle until the 6Cde 9i67 has dissipated, and
the needle can be lifted from the tissue without
effort.
+*-+9Although acupuncture has been widel"
used to treat a !ariet" of painful conditions,
con!incing scientific e!idence for its efficac"
is still lac)ing.$%,$1 0re!ious studies of
acupuncture treatment pro!ide e9ui!ocal
results due to limitations in their design. The
approach of using a double-blind, placebo-
controlled design has man" problems,
including the !irtual impossibilit" of blinding
the acupuncturist, the uncertainties in choosing
a control acupuncture point, and the inherent
difficulties in the use of appropriate controls,
such as placebo and sham acupuncture groups.
There are a few limitations e!ident in this
stud". ?ue to the inherent difficult" in long-
term studies of chronic pain, as discussed
pre!iousl", follow-up of patients was for a
ma-imum of 2% wee)s. Fong-term follow-up
is necessar", howe!er, in order to determine
whether lasting benefits of acupuncture ha!e
occurred. 2ailure to underta)e long-term
follow-up has the potential to produce false-
positi!e outcomes, that is, positi!e outcomes
when no real treatment effect e-ists.
((,+,,$2,$( The lac) of a
placebo or sham
acupuncture control
group in this
clinical trial has
made it impossible
to pro!e whether
needling was an
important part of
the method or
whether the
impro!ement felt b"
the patients in the
e-ercise plus
acupuncture group
was due to the
therapeutic setting
and ps"chological
phenomena.($,$1Altho
ugh significant
impro!ement up to
2% wee)s after
acupuncture
treatment was seen
in this stud", it is
possible that the
6Cplacebogenic67
9ualities of
acupuncture
treatment ma" be
greater than those of
placebo treatments
matched to
drugs.Acupuncture for
frozen shoulder
The imbalance in the number of subects
allocated to the groups is a result of using the
random number table as a randomisation tool.
Though the two groups appeared comparable in
other respects, better randomisation methods,
such as bloc) randomisation, should be utilised
in future studies to ensure e9ual allocation
across groups.
The earlier planned sample size was based
on a large difference in percentage 'SA
impro!ement. This stud", howe!er, re!ealed a
smaller difference than e-pected. Indeed, a
post-hoc power anal"sis showed the power to
detect the currentl" obser!ed differences at #
and 2% wee)s was onl" appro-imatel" +1&
and +(&, respecti!el". This lac) of power,
howe!er, would lower the chance of detecting
a small difference but not increase the chance
of a false positi!e error. ;oreo!er, the
obser!ed difference in the percentage of
impro!ement was based on an intention-to-
treat anal"sis. Thus the obser!ed difference
between the two treatment groups warrants the
attention of further stud", with more refined
planning of sample size.
2ollowing the stud" protocol, the two
groups did not underta)e the same amount of
functional e-ercise. In addition to the group
e-ercise .a total of (#% minutes o!er the
treatment period/ and dail" home e-ercise, the
e-ercise plus acupuncture group also
completed shoulder e-ercises during the
acupuncture treatment .a total of 2+% minutes
o!er the acupuncture treatment sessions/.
;oreo!er, if acupuncture is !iewed as a form
of analgesia, patients who had acupuncture
before e-ercise ma" ha!e demonstrated greater
impro!ement because the" had less pain
during e-ercise. This complicates the
comparisons between the two groups. The
significantl" better outcome of the patients
recei!ing acupuncture in addition to e-ercise
therap" compared with those underta)ing
e-ercise onl" might, to a certain e-tent, be due
to the completion of additional shoulder
e-ercises that were less painful.
?espite the limitations of this clinical trial,
we conclude that the combination of
acupuncture and ph"sical e-ercise ma" be an
effecti!e option in the treatment of frozen
shoulder. This stud" pro!ides additional data
on the potential role of acupuncture in the
treatment of frozen shoulder, particularl" for
those patients not responding well to
con!entional therap".
As most pre!ious studies of acupuncture
were of poor methodological 9ualit", there is
an urgent need for further well-designed
clinical trials in this area. 8igh-9ualit",
double-blind, randomised, shamcontrolled
trials, using ade9uate and !alid acupuncture
8:;< =ol * >o + ?ecember 2%%1 (,
9
Sun et al
treatment regimens should be designed. $+
2uture studies also need to enrol large
numbers of patients, and measure both short-
term and long-term outcomes. ;ore research
is also needed to establish a uniform method
for defining clinical disorders, such as frozen
shoulder, and to de!elop !alid and reliable
outcome measures for these conditions.
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