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Ask an expert - muscles and bones- shoulder

12 questions

Q:  I have a frozen shoulder (and have had it now for 6 months with no sign of recovery). Can acupuncture help and how much does each session cost? On average, how may sessions are needed to treat a frozen shoulder ( know that's like asking 'How long is a piece of string?, but there must be some guideline.

A: 

You will not be surprised to hear that we are often asked this question, and we tend to repeat an answer we gave some time ago.
 

Can accupuncture help a frozen shoulder?

 

Frozen shoulder can be a difficult condition to treat. Our fact sheet on the website 
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/frozen-shoulder.html
 
is not overly encouraging, but the main point to note here is that there haven't been a great many studies. What counts as 'frozen shoulder' can vary considerably and creating a number of groups with identical problems for trial purposes is not that straightforward.

One major problem with the shoulder joint is that it's mobility means a dependence on groups of muscles and a relatively open socket into which the head of the humerus fits. It is very easy for there to be a minor displacement or small dislocation of the joint, and equally easy for a problem with one set of muscles to cause a ripple effect throughout all of the groups holding the shoulder joint stable. There are often secondary problems which may need to be addressed.

Chinese medicine has obviously been used to treat problems like this for thousands of years, and as well as treating locally to where the problem is on the body there are a number of functional treatments which are aimed at affecting all muscles and a couple of 'empirical points', points which have been used for centuries to help with all shoulder problems. There are also points which can be used to help reduce some of the pain and inflammation which results from the muscle and tendon strains.

However, there is no doubt that it really pays to have treatment with someone who fully understands the dynamics of the joint in great detail and can make an informed and careful assessment of the precise problem. There are a considerable number of BAcC members who are also trained in osteopathy and physiotherapy, and equally a number of osteopaths and physios who use acupuncture on a regular basis, and the combination of manipulation, movement and acupuncture may be the optimum package.

It may be helpful to seek the advice of a BAcC member local to you. Most know of colleagues within their area who specialise in this kind of condition, and many also work very closely with local osteopaths and physiotherapists, and maybe able to put together a co-ordinated package of treatment to get you back to good health and mobility. 

 
This remains an accurate summary of our views. Since publishing this, this particular expert has had a couple of good outcomes treating the problem, but the fact that it came as a surprise that it worked so well probably tells you what you need to know about how unpredictable the outcome of treatment can be.
 
The average cost per session depends largely on where you are. For the first session, in London you might be paying £50-£75, for each follow up session (which can last between half an hour and an hour) you might be paying £40-£50. In the provinces this cna be a little lower, £40 - £60, and £30 - £45, but again, it depends on the kinds of premises which you visit. Like any business, the more salubrious the surroundings, the greater the cost and the more likelihood that this will get charged on to the patient.
 
The first session costs more because it is generally longer and is a full diagnostic session. As the great Canadian physician William Osler once remarked, 'tell me about the patient who has the disease, not about the disease the patient has', and this is fundamental to Chinese medicine. The body has a fantastic ability to recover, and looking at the whole picture enables the practitioner to see what is preventing recovery, whether something is simply stuck where the problem is or whether the 'stuckness' is happening because of weaknesses elsewhere.
 
Most practitioners will set a defined number of sessions when taking on a problem like yours and do a thorough review to see if any progress has been made. This is usually four or five sessions. It is very helpful to have some objective markers for checking whether anything has changed, and the degrees of abduction, extension and flexion are usually a reliable indicator of whether joint is is improving or not.
 
We like to avoid situations where treatment just carries on and on after some hold grail of change long after it has become clear that acupuncture treatment is not working. Herein lie complaints!   
 

A:  As you can imagine we have been asked about frozen shoulders before and one of our earlier answers, to which we have added supplementary comment, was:

Can acupuncture help a frozen shoulder?

Frozen shoulder can be a difficult condition to treat. Our fact sheet on the website

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/frozen-shoulder.html

is not overly encouraging, but the main point to note here is that there haven't been a great many studies. What counts as 'frozen shoulder' can vary considerably and creating a number of groups with identical problems for trial purposes is not that straightforward. There was very positive article in the national press a couple of years ago

http://www.dailymail.co.uk/home/you/article-2082722/Health-Take-pain-frozen-shoulder.html

which is useful because it describes a number of conventional treatments which are also used for treating the condition. If you have not been offered any of these options, or not had the full range of investigations, we strongly advise you to make sure that your GP known how much pain you are in and gets the joint scanned to see if there is something which is seriously out of place. It is possible, for example, to tear one of the tendons near the joint which will cause almost unceasing pain, and although acupuncture treatment may help to ease the pain temporarily, the problem may require minor surgery to be fully resolved.

One major problem with the shoulder joint is that it's mobility means a dependence on groups of muscles and a relatively open socket into which the head of the humerus fits. It is very easy for there to be a minor displacement or small dislocation of the joint, and equally easy for a problem with one set of muscles to cause a ripple effect throughout all of the groups holding the shoulder joint stable. There are often secondary problems which may need to be addressed.

Chinese medicine has obviously been used to treat problems like this for thousands of years, and as well as treating locally to where the problem is on the body there are a number of functional treatments which are aimed at affecting all muscles and a couple of 'empirical points', points which have been used for centuries to help with all shoulder problems. There are also points which can be used to help reduce some of the pain and inflammation which results from the muscle and tendon strains.

However, there is no doubt that it really pays to have treatment with someone who fully understands the dynamics of the joint in great detail and can make an informed and careful assessment of the precise problem. There are a considerable number of BAcC members who are also trained in osteopathy and physiotherapy, and equally a number of osteopaths and physios who use acupuncture on a regular basis, and the combination of manipulation, movement and acupuncture may be the optimum package.

It may be helpful to seek the advice of a BAcC member local to you. Most know of colleagues within their area who specialise in this kind of condition, and many also work very closely with local osteopaths and physiotherapists, and maybe able to put together a co-ordinated package of treatment to get you back to good health and mobility.

There isn't a great deal more we can add. Acupuncture has a long history of being used for pain relief, and the question which a practitioner needs to resolve for themselves when treating someone for chronic pain is whether the amount of relief they can help the person to achieve is sustainable enough to warrant the continuing expense. In most cases, however, they will make this a consideration secondary to seeing what can be done to fix the problem itself.

Q: Does acupuncture involve having needles in the head and being put to sleep for bad shoulder pain?  How long is a session?

A:   To answer your second question first, the majority of BAcC members would normally allocate between half an hour and an hour for a session of acupuncture. Some work slightly more quickly, with twenty minute sessions, and occasionally some members with adequate treatment space will let a patient relax after treatment for as much as another half an hour.
 
As far as the location of points is concerned, Chinese medicine is premised on an understanding of the flow of energy, called 'qi', in the body and its rhythm, balance and flow. The pattern of flow is reflected in a number of channels which traverse the body, and blockages or changes in the flow can have effects elsewhere in the body because of the complex interconnections. So, it would not be unusual for needles to be placed in the feet, for example, to deal with headaches if a blockage had to be dealt with there.
 
One of our colleagues used to use the analogy of a central heating system to explain this to patients. Because it is a closed system a problem with a thermostat or valve can affect the pipes at the other end of the house. His practice used to have a number of patients happily telling their friends that they had problems with their thermostats!
 
Chinese medicine also recognises that when problems arise in specific areas this may not always be because of a local injury. If the whole system is weakened, then where a symptom appears may simply be one of a number of weak points. The skill of the practitioner often lies in determining whether a shoulder pain or knee pain is a local problem or a local problem which has arisen because of a more generalised weakness. In both cases there are likely to be needles in or near the affected area, but in the latter case the needles may go where the system needs to be boosted.
 
Sleeping or becoming very relaxed when being needled is not uncommon. Many patients drop off when they are being treated, and many practitioners are happy to let them drift. Most people in modern life are busy and stressed, and there is a common belief that letting someone drift slightly removes some of the barriers to effective treatment which can be created by a patient arriving tense and being in a hurry to get back to work.
 
Your practitioner is your best source of information, though. Our members are more than happy to explain what they are doing, and give you an insight into the way that Chinese medicine works. 
 

 

Q:  Would acupuncture help with a chronic nerve pain which I have in my shoulder which refers down to my forearm?

A:  A great deal depends on whether the pain is caused by impingement of a nerve, either in the shoulder itself or higher up in the neck, which can also produce similar sensations. If there is a structural problem, then while acupuncture treatment may help to reduce any inflammation which results from the trapped nerve, the problem will recur until the structure is fixed. While acupuncture treatment aims to restore natural function, and may eventually encourage the structure to right itself, the quickest way to deal with a problem such as this may be to visit an osteopath. They will be able to tell you whether there is a problem, and perhaps re-refer you to an acupuncturist after they have corrected it. We find this kind of cross-referral often works well; once the structure is settled it is important to get the muscles and tendons to re-assume their correct positions and tension. Acupuncture treatment seems to help well with this.

However, this is to take a very Western view of what is going on, and there are many occasions when the sensation which someone describes can be explained, understood and treated in Chinese medicine by using a different way of looking at the body. From a Chinese medicine perspective, which is premised on a good flow of energy (called 'qi') in the body, pain arises from deficiencies, excesses or blockages in the flow. The exact nature of the pain will inform the practitioner about the exact nature of the blockage. It is perfectly possible that working in this way the pain can be treated.

The best advice we can give, though, is to visit a BAcC member local to you for a brief face to face assessment of whether they can help with the problem. It is very difficult to tell at one remove what the best course of action is, and a visual inspection would help to determine whether or not an onward referral to an osteopath is more appropriate.

Q:  I injured my shoulder windsurfing and having rested it and resorted to a a sports massage (which made the pain worse). I wondered if acupuncture might help?

A:  A great deal depends on the nature of the injury. The shoulder is a very tricky joint to deal with, as your sports massage therapist may have told you. The gleno-humeral cavity, the very loose ball and socket arrangement which gives the shoulder its extreme mobility compared, say, to the hip joint, means that its stability depends on several layers of muscle and a rotator cuff. If any of these is inflamed, torn or damaged, it can throw the whole alignment of the joint out, and this can work against recovery, especially since the shoulder is a difficult joint to immobilise and continue to function as normal.

We are not surprised that treatment made the pain worse. It is often the case that correcting a joint problem after it has become 'set' for a while can make the muscles ache a great deal. However, this should be a short-term and transient effect, and if it continues to happen, then it may well be that direct treatment is simply aggravating the problem. Acupuncture practitioners occasionally find the same thing happens if they treat an inflamed area to reduce heat and swelling; it can feel rather like poking a sleeping dragon, and make attempts to treat feel very uncomfortable. The advantage of using acupuncture, however, is that the system of Chinese medicine is based on theories of flow and balance of an energy, called 'qi', and one does not need to needle directly into the place where the pain is. Often we find that treating at a distance, 'distal treatment', by using points further down the limb or occasionally on the opposite limb or even equivalent lower limb, can have profound effects. This can all seem very mysterious to someone with no experience of Chinese medicine, but we find that once we show patients some of our charts and books, it makes perfect sense.

The best advice we can give you is to visit a BAcC member local to you and seek their advice. Shoulder problems tend to be unique and different, even in western medicine, and this will determine whether they recommend acupuncture treatment for you. You will almost certainly need to be following a course of excercise and movement at the same time to regain your proper strength and co-ordination, especially since you are very likely to be back on a board as soon as you are better. It might well be worth asking a local BAcC member if they, or a colleague, have this kind of experience - our members are happy to network to make sure that someone gets the best possible outcome. It may even be worth considering going to a physiotherapist who also uses acupuncture, as many now do, to get the best of both, although, obviously, we believe that as the 'experts' in acupuncture, you would be better off initially having your acupuncture treatment from someone who uses this as their full time job rather than simply as another tool in the toolbox.

 

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