Outpatient Case Study-Shoulder Pain

Outpatient Case Study from a student’s perspective…

Clinical Scenario:

Patient is a 63-year-old female who presents to physical therapy with left shoulder pain that started 3 months ago. Patient said that she was lifting an object from overhead when she felt sudden pain in her left shoulder. Patient also said that sleeping is okay, but can be uncomfortable if she tries to sleep on her left side. Additionally, brushing her hair and doing anything above shoulder height is very difficult and causes her pain. Patient is very active and says that her shoulder pain is limiting her from bending her arm, lifting, and working out. Patient went to the MD where she had an x-ray done; x-ray was negative for bone spurs. MD told the patient that she may have bursitis and was sent to physical therapy to treat. Patient has had two cortisone injections into her left shoulder, both which have helped to some degree.

During the examination, it was noted that the patient presented with rounded shoulders and a forward head position during stance. Patient was able to perform all cervical AROM within normal limits (WNL), as well as elbow AROM. Patient’s shoulder AROM was assessed and noted that left shoulder flexion was limited to 135-degrees and abduction to 87-degrees. The right side was compared; shoulder flexion reached 171-degrees and abduction 175-degrees. Patient’s external rotation and internal rotation was WNL on the right side, however left external rotation measured 45-degrees and internal rotation was 10-degrees. Gross muscle testing was examined with both cervical flexion and extension a 4+/5. Patient’s right shoulder flexion, abduction, elbow flexion and extension were all 4+/5. Left shoulder flexion, abduction, elbow flexion and extension all measured 4-/5. Patient’s myotomes and dermatomes all tested normal. Power grip was assessed, with right handedness noted. Patient’s grip on the right was 17 kg and left grip was 14 kg. Special tests were not assessed during the time of the examination due to patient apprehension to move her left shoulder. When palpating around the left glenohumeral joint, patient had moderate tenderness along her left levator scapulae, upper trapezius, supraspinatus, and infraspinatus. After further evaluation, patient was given a physical therapy diagnosis of “adhesive capsulitis.”  

After a complete and thorough examination, I was interested to see if dry needling to the patient’s peri-scapular area would increase her ROM faster than manual therapy alone. Patient’s first two treatment session consisted of manual therapy and PROM alone to assess how much ROM the patient could achieve. After one week, dry needling was performed to the same area that manual therapy was administered to see if further ROM could be achieved. Further treatment is detailed below.   

Focused Question:

In a patient with adhesive capsulitis, what will produce the greatest ROM- dry needling plus manual therapy or manual therapy alone? And which intervention will have the greatest improvements within a 12-week period?

Articles Selected for Appraisal and Summary of Their Study Design:

Articles Selected for Appraisal and Summary of Their Study Designs

Level of Evidence References *

References for all articles selected for and used in the appraisal.  Please list in hierarchical order (1-5) of evidence; min total of 4. (AMA)

Study Design
  1. Clewley D, Flynn T, Koppenhaver S. Trigger Point Dry Needling as an Adjunct Treatment for a Patient with Adhesive Capsulitis of the Shoulder. Journal of Orthopaedic & Sports Physical Therapy. 2013;44(2):92-101. https://www.jospt.org/doi/abs/10.2519/jospt.2014.4915. Accessed July 24, 2018.
Case Report
  1. Bron C, Wensing M, Franssen JL, Oostendorp RA. Treatment of myofascial trigger points in common shoulder disorders by physical therapy: A randomized controlled trial [ISRCTN75722066]. BMC Musculoskeletal Disorders. 2007;8:107. doi:10.1186/1471-2474-8-107. Accessed July 24, 2018.
Randomized Control Trial
  1. Palomares S, Blazquez B, Palomares A, Calvo E, Benito M, Lapena E, Beldarrain M, Botaya R. Contributions of Dry Needling to Individualized Physical Therapy Treatment of Shoulder Pain: A randomized clinical trial. Journal of Orthopaedic & Sports Phyiscal Therapy. 2016; 47(1):11-20. https://www.jospt.org/doi/abs/10.2519/jospt.2017.6698. Accessed July 24, 2018.
Randomized Control Trial
  1. Liu L, Huang Qm, Liu QG, Ye G, Bo CZ, Chen MJ, Li P, et al. Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck and Shoulder Pain: A systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(5):944-55. https://www.ncbi.nlm.nih.gov/pubmed/25576642. Accessed July 24, 2018.
Systematic Review
  1. Bron C, et al. Prevalence of MTrPs in Patients with Shoulder Pain. Dry Needling for Craniofacial, Cervicothoracic & Upper Extremity Conditions: An Evidence-Based Approach. 2011;9(6):117-118.
Systematic Review  
  1. Langevin HM, Schnyer R, MacPherson H, et al. Manual and Electrical Needle Stimulation in Acupuncture Research: Pitfalls and Challenges of Heterogeneity. Journal of Alternative and Complementary Medicine. 2015;21(3):113-128. doi:10.1089/acm.2014.0186. Accessed July 24, 2018.
Systematic Review
Total Number of Articles 6

Summary of Key Findings:

In a case report by Clewley et al, 1 they looked at a 52-year-old female with primary symptoms of shoulder pain and decreased motion, secondary to adhesive capsulitis. The authors initially treated the patient with joint mobilizations to the shoulder region and trust manipulations to the cervicothoracic region. However, the patient continued to have pain and limited motion in her shoulder. On the third visit, the patient was treated with dry needling targeting the upper trapezius, levator scapulae, deltoid, and infraspinatus muscles. The patient was treated with dry needling for 10 visits, with improvements in pain-free ROM and an increase in functional outcome measures, like the DASH and Shoulder Pain and Disability Index. In conclusion, the authors found that when incorporating dry needling into the treatment sessions, the patient seen rapid improvements in ROM. Additionally, the authors suggested that the above musculature is a great source of pain in regard to adhesive capsulitis.

Bron et al,2 conducted a randomized control trial to investigate whether physical therapy modalities could inactivate trigger points in order to reduce symptoms and improve shoulder function in a chronic, non-traumatic shoulder population. They compared the modalities to a wait-and-see approach that many people often use when dealing with shoulder injuries. One hundred subjects between 18 and 65 years old were included, all with unilateral shoulder pain, and sent to physical therapy to treat the neck, shoulder, or, arm. Patients completed the DASH for baseline testing measures and myofascial trigger points were identified before beginning. The control group took the wait-and-see approach and the intervention group received physical therapy. At the 12-week mark they all received the same physical therapy program and were re-evaluated using the DASH. The physical therapists used stretching, compression, and cryotherapy in order to decrease pain and symptoms, whereas the control group just used over-the-counter painkillers. Researchers found that stretching and compression to trigger points increased patients’ ROM and decreased pain sensitivity when comparing to just taking medication alone.  

Palomares et al, 3 conducted a randomized clinical trial intended to treat MTrPs with dry needling. One hundred twenty patients were looked at, all of which had nonspecific shoulder pain. Subjects were randomly placed into either a physical therapy treatment group or a trigger point dry needling plus physical therapy group. Patients were measured in regard to pain and function and the number of active MTrPs were calculated. Investigators found that there was no significant difference between evidence-based physical therapy treatment compared to dry needling, both showed significant improvements over time.

Liu et al,4 evaluated dry needling used as the main treatment in patients diagnosed with MTrPs associated with neck and shoulder pain. Two independent reviewers looked at twenty randomized controlled trials involving 839 patients and found that dry needling for MTrPs was effective in short term (3 days) and medium term, however wet needling was more effective to treat trigger points for medium term cases.

Bron et al,5 looked at the prevalence of MTrPs and the correlation between MTrPs and pain intensity in patients with chronic, non-traumatic unilateral shoulder pain. Researchers found that all 72 subjects that were studied had active MTrPs and 67/72 had latent MTrPs. Active MTrPs were found in the infraspinatus, upper trapezius, middle trapezius, anterior deltoid, middle deltoid, posterior deltoid, and teres minor. Latent MTrPs were found in the infraspinatus, upper trapezius, teres major, and anterior deltoid. Examiners found that the infraspinatus and upper trapezius muscles were the most common muscles to have active MTrPs. By treating the active trigger points, patients were able to have a more normal activation pattern and had spontaneous recovery of shoulder pain.

Langevin et al, 6 evaluated the benefits and modes between electrical acupuncture versus manual acupuncture. The authors found that MA encompasses a much shorter duration than EA and provides a brief, intermittent stimulation to the muscle. On the other hand, EA provides a constant stimulation that causes depolarization of the muscles for several minutes (15-30 minutes). Depending on the duration of stimulation and mechanism of acupuncture that is being elicited to the muscle, there are different physiology responses that can occur. The authors looked at 89 systematic reviews and found that EA is superior to MA when treating knee OA. Lastly, the authors suggest that many factors play a role in comparing the two modes, including: mechanism of action, clinical recommendations, and patterns of use; which the authors state is widely different across practitioners. The authors suggest that both EA and MA are beneficial, however it just depends on clinician preference, treatment area, and patient symptoms.   

Limitations that would apply to Clewley et al would be that they only looked at one individual patient’s outcomes, rather than examining a larger subject field. By doing this, readers cannot conclude whether DN would work for their patients because it was administered to a female, of a specific age, with a specific diagnosis. Contrarily, Bron et al looked at a large range of ages within their study. Although this is better for data collection purposes, age can play a role in shoulder function and pain perception/sensitization. I think future studies should look to see how dry needling varies across multitudes of ages and compare outcome measures based on improvements in ROM and pain perception via the DASH.

Application to Patient Care:

For this particular patient case, I wanted to apply a similar study design like that of Clewley et al,1 but apply dry needling to the same musculature as Bron et al.5 In my patient case, we decided to treat the patient with just manual therapy for the first two visits. Manual therapy consisted of massaging the patient’s active MTrPs within the left trapezius, levator scapulae, rhomboid major and minor, serratus posterior superior, latissimus dorsi, serratus anterior, deltoid, supraspinatus, infraspinatus, teres major and minor, subscapularis, pectoralis major and minor, and coracobrachialis. Additionally, PROM was performed into shoulder abduction and flexion to stretch the left latissimus dorsi and RTC musculature.  On the initial evaluation, patient was able to reach 87-degrees of left shoulder abduction and 135-degrees of left shoulder flexion. After the second visit with just manual therapy and PROM alone, patient gained 3-degrees of shoulder abduction. Patient was unable to improve in shoulder flexion. During the third visit, patient was administered manual therapy to the same muscles and then dry needling was applied. DN was performed x 15 mins at 2Hz for 250usec to the patient’s left shoulder. 25-40 mm single use needles were administered and individually wrapped with guide tube (Sierin) were utilized. Needles were inserted targeting: trapezius, levator scapulae, rhomboid major and minor, serratus posterior superior, latissimus dorsi, serratus anterior, deltoid, supraspinatus, infraspinatus, teres major and minor, subscapularis, pectoralis major and minor, and coracobrachialis. Unilateral spins were applied to all needles, as well as slight tenting. Patient was sidelying with ipsilateral UE resting on a pillow. Patient responded as expected, with mild deqi response noted. Patient did not have significant pain and was able to tolerate treatment. Patient was also educated on the effects of DN and what to expect over the next few days. Needles were counted upon insertion and all needles were accounted for upon removal.

After two visits of administering manual therapy plus dry needling, patient has had an additional 5-degree improvement in shoulder abduction and 4-degree improvement in shoulder flexion. Patient has also stated that her pain has decreased significantly with shoulder all motions. Patient will continue to be evaluated for the next 10 visits to see how effectiveness dry needling is on the patients shoulder mobility.

Clinical Instructor Feedback:

My CI is on board with implementing the plan above and thinks that dry needling is a good recommendation for this patient, especially when treating adhesive capsulitis. CI said that dry needling will facilitate breakdown the adhesions within the glenohumeral joint since manual therapy alone cannot. My CI discussed that there is a neurophysiological response that occurs once the skin is punctured that releases opioid  and non-opioid factors that are found present in the tissue for 7-10 days post treatment, Thus performing this treatment allows for the patient’s healing of the injury to continue upon leaving. This response can be exaggerated by piggybacking the days that the patient gets the needling performed. We are also using 25 mm to 40 mm needles, thus we are able to access areas of the joint that we are not able to normally access. One in particular is the area of the supraspinatus that is deep to the AC joint and rarely able to be stimulated. She has seen great improvements in shoulder injuries when this area is addressed with the DN. CI also says that dry needling will be beneficial to administer for the next couple visits to see if further improvements are able to be made. After proper lengthening of above musculature is addressed and relieved, then the patient will progress into a strengthening program.

Data Bases and Sites Searched:

  1. Journal of Orthopaedic & Sports Physical Therapy (JOSPT)
  2. PubMed
  3. PEDro
  4. Physiopedia
  5. PTNow
  6. Journal of Alternative and Complementary Medicine
  7. Osteopractor WordPress
  9. Dry Needling Institute: American Academy of Manipulative Therapy