Trigger point dry needling as an adjunct treatment for a patient with adhesive capsulitis of the shoulder.

[

case report

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Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at University of Pittsburgh on June 2, 2014. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

DEREK CLEWLEY, PT, DPT, OCS, FAAOMPT1 • TIMOTHY W. FLYNN, PT, PhD, OCS, FAAOMPT2 • SHANE KOPPENHAVER, PT, PhD, OCS, FAAOMPT3

Trigger Point Dry Needling as an Adjunct Treatment for a Patient With Adhesive Capsulitis of the Shoulder

A

The economic burden and the dhesive capsulitis is a common shoulder condition impact of adhesive capsulitis of unknown etiology that is often treated by physical on health care expenditures are therapists.26,47 The incidence rate of adhesive capsulitis is SUPPLEMENTAL VIDEO ONLINE significant.9,43 The condition has higher in women than in men and higher among middlebeen described as self-limiting, aged individuals.47 The risk factors associated with adhesive typically resolving in 1 to 3 years, capsulitis are type 1 or 2 diabetes mellitus, thyroid disease, an age of with long-term range of motion (ROM) between 40 and 65 years, trauma, prolonged immobilization, autoimmune disease, and myocardial infarction.23 In TTSTUDY DESIGN: Case report.

TTBACKGROUND: Prognosis for adhesive capsuli-

tis has been described as self-limiting and can persist for 1 to 3 years. Conservative treatment that includes physical therapy is commonly advised.

TTCASE DESCRIPTION: The patient was a

54-year-old woman with primary symptoms of shoulder pain and loss of motion consistent with adhesive capsulitis. Manual physical therapy intervention initially consisted of joint mobilizations of the shoulder region and thrust manipulation of the cervicothoracic region. Although manual techniques seemed to result in some early functional improvement, continued progression was limited by pain. Subsequent examination identified trigger points in the upper trapezius, levator scapula, deltoid, and infraspinatus muscles, which were treated with dry needling to decrease pain and allow for higher grades of manual intervention.

TTOUTCOMES: The patient was treated for a

total of 13 visits over a 6-week period. After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range

individuals with diabetes, the incidence rate is upward of 20%, compared to 2% to 5% in individuals without diabetes.15,37 of motion and functional outcome measures, assessed with the Shoulder Pain and Disability Index and the shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire, exceeded the minimal clinically important difference after 2 treatment sessions. At discharge, the patient had achieved significant improvements in shoulder range of motion in all planes, and outcome measures were significantly improved.

TTDISCUSSION: This case report describes

the clinical reasoning behind the use of trigger point dry needling in the treatment of a patient with adhesive capsulitis. The rapid improvement seen in this patient following the initiation of dry needling to the upper trapezius, levator scapula, deltoid, and infraspinatus muscles suggests that surrounding muscles may be a significant source of pain in this condition.

TTLEVEL OF EVIDENCE: Therapy, level 4. J

Orthop Sports Phys Ther 2014;44(2):92-101. Epub 21 November 2013. doi:10.2519/jospt.2014.4915

TTKEY WORDS: frozen shoulder, soft tissue, upper trapezius

deficits lasting up to 10 years.27 However, the prognosis associated with adhesive capsulitis improves with a lesser number of comorbidities.48 There are a number of invasive and conservative options for managing adhesive capsulitis.7,8,13,23,44 Invasive interventions include intra-articular steroid injection, surgery, and manipulation under anesthesia. Manipulation under anesthesia is commonly used but carries the risk of humeral fracture, dislocation, rotator cuff injuries, labral tears, and brachial plexus injury.13 Acetaminophen and nonsteroidal anti-inflammatory medications are common first-line nonsurgical treatments for adhesive capsulitis, but there is little evidence for their effectiveness.44 Oral corticosteroids might provide short-term benefit in pain relief and improved ROM in patients with adhesive capsulitis.7 However, they have not been proven to reduce the duration of adhesive capsulitis.8 Early physical therapy intervention that includes joint mobilization directed at the shoulder joint complex has been

BenchMark Physical Therapy, Atlanta, GA. 2Department of Physical Therapy, Rocky Mountain University of Health Professions, Provo, UT. 3US Army-Baylor Physical Therapy, Waco, TX. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Derek Clewley, BenchMark Physical Therapy, 4485 Pinehollow Court, Alpharetta, GA 30022. E-mail: djclewpt@ gmail.com t Copyright ©2014 Journal of Orthopaedic & Sports Physical Therapy® 1

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shown in some studies to improve the rate of recovery.28,49,50 Jewell et al20 concluded in a retrospective cohort study that the use of joint mobilization and exercise was associated with improved outcomes, whereas poor outcomes were associated with providing massage, ultrasound, phonophoresis, and iontophoresis as the primary interventions. Stretching exercises are advocated for patients with adhesive capsulitis.12,16,23 In a study by Griggs et al,16 in which patients performed a home exercise program that consisted of passive stretching into shoulder abduction, flexion, and internal and external rotation, active shoulder flexion increased 43°, active external rotation 25°, passive internal rotation 8 vertebral levels, and the overall glenohumeral rotation arc at 90° of abduction increased 72°. Furthermore, 90% of the patients reported satisfaction with treatment. Five patients who had unsatisfactory outcomes received a manipulation under anesthesia. Although performing higher-grade glenohumeral joint mobilizations is associated with greater increase in ROM,21,45 patients may have difficulty tolerating these higher-grade mobilizations, as they often elicit pain. Therefore, management of pain associated with adhesive capsulitis is often needed prior to engaging in treatments that are more aggressive. Thrust manipulation of the thoracic spine has been shown to provide shortterm benefits for patients with subacromial impingement syndrome.4 However, the effectiveness of this intervention for individuals with adhesive capsulitis is unclear, secondary to a lack of published evidence. Dry needling has been purported to be effective for reducing pain and improving ROM.11,17 An educational resource paper published by the American Physical Therapy Association2 describes dry needling as a skilled intervention performed by physical therapists that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points and muscular and connective tissues for the management of neuro-

musculoskeletal pain and movement impairments. A trigger point is a taut band of skeletal muscle located within a larger muscle group. Trigger points can be tender to the touch and can refer pain to nearby parts of the body. Physical therapists utilize dry needling with the goal of releasing/inactivating the trigger points and relieving pain.2 Dry needling has been demonstrated to be an effective intervention for patients with chronic shoulder pain and ROM deficits.18 A case series by Osborne and Gatt33 showed improved shoulder ROM and function in elite-level volleyball players after dry needling of the scapulohumeral muscles. In a case series by Ingber,19 3 patients with shoulder pain were treated with dry needling of the shoulder-region muscles. They had painfree ROM at the end of their treatment, which persisted at a 2-year follow-up. However, no evidence exists for dry needling as an effective intervention for loss of shoulder ROM and function associated with adhesive capsulitis. The purpose of this case report was to describe the examination and treatment, including the clinical reasoning leading to the use of dry needling, of a patient with adhesive capsulitis.

CASE DESCRIPTION History

T

he patient was a 54-year-old right-handed woman who was referred to physical therapy by her orthopaedic surgeon, with a diagnosis of left shoulder adhesive capsulitis. She had a 5-month history of left shoulder pain and stiffness, with an insidious onset. She denied any trauma to the neck or the shoulder and any previous history of neck or shoulder problems. The patient’s past medical history was reviewed with the patient for all systems, and her past medical history was insignificant for nonmusculoskeletal contributions, including type 1 or 2 diabetes mellitus, autoimmune disease, thyroid disease, and myocardial infarction. Two

areas of pain were described by the patient. The first area (P1, FIGURE 1) was located along the lateral aspect of the left shoulder. Using an 11-point numeric pain rating scale (NPRS), her pain in this location was rated as 4/10 at its lowest and 8/10 at its worst. The NPRS has been demonstrated to be a reliable pain scale for patients with shoulder dysfunction. 31 The patient described the pain as a burning and throbbing sensation aggravated with activities requiring her to reach behind her back, including donning and doffing a bra or reaching into a back pocket. She also had pain with overhead reaching activity, including reaching into a high cabinet or performing her hair care. Onset of pain was immediate with these movements, and ease of pain occurred immediately after taking her arm out of position. The second area of pain (P2, FIGURE 1) was defined as an area over the anterolateral humerus around the deltoid insertion. The intensity of pain on the NPRS was similar to that described in P1, with the same aggravating/easing factors. The cervicothoracic area, arms, and forearms were reviewed for pain, and the patient denied any pain in these regions.

Examination/Evaluation Prior to the physical examination, the patient completed a series of outcome measures to be assessed throughout the plan of care. The patient had a score of 68 points on the shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), which is scored from 0 to 100, with 0 indicating less disability. This outcome measure has been shown to have good test-retest reliability (intraclass correlation coefficient greater than 0.90) and construct validity.31 The minimal clinically important difference (MCID) on the QuickDASH has been reported to be an 8-point change. 31 The patient also completed the Shoulder Pain and Disability Index (SPADI) and had an initial score of 55 points. The SPADI has been shown to have slightly better responsiveness than the Quick-

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FIGURE 1. Pain diagram. P1 and P2 indicate 2 distinct areas of perceived pain by the patient.

Active and Passive Shoulder Range of Motion at Baseline

TABLE 1 Left Active

Left Passive

Right Active

Right Passive

Flexion, deg

90 (5 P1, 10 P2)*

110 (5 P1, 10 P2)*

170

180

Abduction, deg

88 (5 P1, 10 P2)*

94 (5 P1, 10 P2)*

170

180

Internal rotation, deg

…

30†

…

70‡

External rotation, deg

…

20

…

80‡

†

*Values in parentheses are pain, as measured on an 11-point numeric pain rating scale, where 0 is no pain and 10 is maximum tolerable pain, with P1 and P2 corresponding to pain in 2 separate locations over the shoulder region (FIGURE 1). † Measured at 45° of shoulder abduction. ‡ Measured at 90° of shoulder abduction.

DASH and is a recommended outcome measure for patients with shoulder-specific diagnoses.38,42 The SPADI is scored from 0 to 100, with lower scores indicating less disability. The SPADI has been

shown to have good test-retest reliability (intraclass correlation coefficient greater than 0.89),5 with an MCID between 8 and 13 points.35 The patient’s cervicothoracic spine

was examined as a possible source of shoulder pain. A detailed routine exam in the sitting position that included cervical active ROM with overpressure was performed. Additionally, the Spurling A and cervical distraction tests were performed.46 Cervicothoracic passive intervertebral mobility testing was assessed, and hypomobility was noted in the cervical and thoracic spine. None of the tests and measures elicited pain in the shoulder or neck. The right shoulder, elbow, wrist, and hand were assessed and were considered to have normal ROM and strength, and all special tests for shoulder impingement or instability were considered negative. Both shoulders were assessed. Active shoulder ROM was assessed in the seated position, followed by passive ROM assessment in the supine position (TABLE 1). Strength testing, performed in a seated position,36 indicated that the left shoulder was generally rated at a 2+/5, secondary to the patient not being able to reach full active or passive ROM. None of the strength measures elicited the left shoulder pain, and she was able to tolerate resistance in reduced ranges. Elbow and wrist strength on the left side was normal and rated at 5/5. The HawkinsKennedy, painful arc of motion, and infraspinatus muscle tests were included as a test-item cluster for subacromial impingement syndrome.34 The negative likelihood ratio for the patient not having the condition when all 3 tests are negative is 0.17. The only positive test was the Hawkins-Kennedy, which elicited 5/10 pain in both the P1 and P2 regions. The patient was unable to achieve sufficient shoulder ROM to perform an accurate painful arc test. Infraspinatus muscle testing did not cause any pain in the shoulder. It has been reported that in patients with suspected adhesive capsulitis, the special tests associated with other diagnoses, such as subacromial impingement, become even more sensitive when negative.27 Palpation of the left supraspinatus and long head of the biceps tendon did



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not reproduce the patient’s shoulder pain. Palpation of the supraspinatus muscle is a widely used test for the diagnosis of subacromial impingement syndrome and has been found to be a highly sensitive test.40 However, the reliability of this test is limited, as levels of palpation cannot be objectively measured. No other palpation was performed on the first visit, secondary to the shoulder’s high irritability level. Passive joint mobility assessment of the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints did not reproduce the patient’s symptoms. However, hypomobility of the glenohumeral joint was noted in all directions (anterior-to-posterior, posteriorto-anterior, and inferior glides) in the left shoulder compared to the right shoulder.

Diagnosis/Prognosis Upon completion of the examination, the therapist concluded that the patient’s signs and symptoms were consistent with stage 2 adhesive capsulitis.23 The clinical course of adhesive capsulitis has been well described as a continuum of 4 stages,23,32 with stage 2 lasting from 3 to 9 months and characterized by a gradual loss of motion in all directions due to pain.23,32 Subacromial impingement syndrome was ruled out secondary to 2 of 3 tests being negative in the test-item cluster described by Park et al.34 Referral of pain from pathology at the cervical spine was ruled out, based on a detailed examination of that region, with all measures and tests being negative.

Intervention The patient was seen for a total of 13 treatment sessions over a period of 6 weeks. Treatment Sessions 1 and 2 A seated cervicothoracic thrust manipulation technique was performed during the first 2 therapy sessions. The use of cervicothoracic manipulation has been associated with positive outcomes for patients with subacromial impingement syndrome; however, it has not been assessed for effectiveness in patients with adhesive cap-

sulitis.30 This technique was also selected based on the clinical concept of regional functional interdependence between the cervical spine and the shoulder complex, even in the absence of specific cervical impairments.39 At the first treatment session, the patient had immediate improvements in active shoulder flexion ROM to 110° and active shoulder abduction to 105°. Based on these immediate gains in ROM, the patient was instructed in performing seated active thoracic extension self-mobilizations using a chair back, with arms crossed over chest, as a home exercise program. No other exercises were performed or provided as part of a home exercise program, secondary to the patient’s high level of shoulder irritability. At the start of the second treatment session, the patient reported increased functional ROM that included the ability to reach the top of her head. Her pain ratings on the NPRS had not changed since the first visit, and she reported that the pain woke her up the night following the previous session. She was able to demonstrate good performance of the thoracic self-mobilization exercise. At this second session, a seated thoracic thrust manipulation was performed, based on a similar clinical reasoning that led to performing the cervicothoracic thrust manipulation during the first treatment session. Following the manipulation, active shoulder flexion ROM was increased to 135° and active shoulder abduction ROM increased to 110°. A seated cervicothoracic thrust manipulation was then performed, but without further gains in shoulder ROM or a decrease in pain. Passive ROM into flexion, abduction, external rotation, and internal rotation was initiated after the thoracic and cervicothoracic thrust manipulations. However, the patient reported an increase of pain at the end of range in all planes with passive ROM to 7/10 on the NPRS. Therefore, secondary to patient guarding and high irritability with passive ROM, especially with hand placement over the glenohumeral joint, the acromioclavicu-

lar and sternoclavicular joints were mobilized, as opposed to the glenohumeral joint, with the goals of reducing pain, restoring mobility of the shoulder complex, and allowing the treating physical therapist to perform higher-grade passive ROM. After mobilization of these joints, the patient showed improved tolerance to shoulder flexion and abduction passive ROM, but changes in ROM were not noted. Ten minutes of low-resistance, upper-body ergometer exercise was added for improved circulation and mobility. Treatment Session 3 After the second session, the patient described an increase in shoulder pain that interrupted her sleep. At the beginning of the session, her resting pain level was 4/10, and she did not report improved function following the second treatment session. All manual interventions were performed in the same manner as those in session 2, with only slight increases in ROM compared to session 2 but decreased pain at the end of motions. Upon further palpation assessment on this visit, the patient presented with active trigger points of the upper trapezius and levator scapula muscle bellies. Dry needling was performed to target these trigger points, with the goal of decreasing pain associated with them.41 The left upper trapezius muscle was palpated and an active trigger point was noted that reproduced the patient’s left shoulder pain. A 0.25 × 40-mm J-Type needle (SEIRINAmerica, Weymouth, MA) was used. The needle was inserted and a local twitch response (LTR) was observed. The needle was oscillated until the LTR attenuated and the patient adapted to the stimulus. The needle was discarded and another needle was used in a different location in the upper trapezius. At this new location, an LTR was elicited and continued until the response attenuated. Active shoulder flexion and abduction ROM was then reassessed. There was no gain in ROM compared to pre–dry needling measurements, but the patient reported no pain at the end range. The patient was instructed to perform active shoulder flex-



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[ ion and abduction ROM exercises in the pain-free range of movement at home. Treatment Session 4 The patient returned for the fourth treatment session with a report of marked improvement. Her resting pain was now 0/10 on the NPRS and was 3/10 with activities requiring external and internal rotation of the shoulder, such as reaching to the back of her head and into her back pocket. Active shoulder flexion and abduction ROM were 135° and 120°, respectively, limited by tissue resistance rather than pain, which was the previous limiting factor. During this treatment session, the interventions provided were similar to those performed during the third therapy session, except that the patient performed 10 minutes of light resistance on the upper-body ergometer and active shoulder ROM exercises prior to treatment with manual therapy techniques. Thoracic and cervicothoracic thrust manipulation techniques were provided but led to minimal gains in ROM. Mobilizations to the acromioclavicular and sternoclavicular joints were not performed, secondary to a lack of change during the previous treatment after these techniques were performed. The glenohumeral joint was not mobilized due to the patient’s tenderness when the therapist’s hand was placed over the anterior shoulder. Subsequently, dry needling was performed in the same manner as in session 3, with the addition of treating the infraspinatus and deltoid, secondary to painful trigger points identified in these muscles at this visit, and elicited familiar pain. An LTR was noted when treating trigger points in the upper trapezius but not for those in the deltoid and infraspinatus. Following treatment, active shoulder ROM was 150° for flexion and 135° for abduction. End-range active shoulder flexion and abduction did not elicit pain in the shoulder. Treatment Session 5 Pain reported by the patient at rest was maintained at 0/10 on the NPRS, and pain was 2/10 with active shoulder abduction. The patient was now able to reach the top of her head without

case report TABLE 2

] Summary of Plan of Care

Treatment Session Exercises

Manual Therapy and Dry Needling

Session 1, week 1

• Over-the-chair thoracic extension

• Thrust manipulation, cervicothoracic region

Session 2, week 1

•O ver-the-chair thoracic extension • Upper-body ergometer

• T hrust manipulation, cervicothoracic and thoracic • AC and SC joint mobilization • PROM shoulder flexion, abduction, and external rotation

Session 3, week 2

•O ver-the-chair thoracic extension • Active ROM exercises for shoulder flexion and abduction • Upper-body ergometer

• T hrust manipulation, cervicothoracic region • AC and SC joint mobilization • PROM shoulder flexion, abduction, and external rotation • Dry needling, upper trapezius

Session 4, week 2

•U pper-body ergometer • Active ROM exercises for shoulder flexion and abduction

• T hrust manipulation, cervicothoracic region • Dry needling, upper trapezius, deltoid, and infraspinatus

Session 5, week 2

•U pper-body ergometer • Active ROM exercise for shoulder flexion and abduction • Isotonic exercises for the rotator cuff and deltoid

• T hrust manipulation, cervicothoracic region • Glenohumeral, AC, and SC joint mobilization with PROM shoulder flexion, abduction, and external rotation • Dry needling, upper trapezius, levator scapula, deltoid, and infraspinatus

Session 6, week 3

• Same as session 5

• T hrust manipulation, cervicothoracic region • Glenohumeral, AC, and SC joint mobilization with PROM shoulder flexion, abduction, and external rotation • Dry needling, deltoid only

Session 7, week 3 Session 8, week 4

•A dded towel stretch for shoulder internal rotation

•G lenohumeral joint mobilization, PROM into flexion, abduction, and external and internal rotation

Session 9, week 4 • Progressed prone scapulothoracic and Sessions 10 and 11, supine serratus exercises with increased week 5 resistance and repetitions Sessions 12 and 13, • Continued with shoulder exercises for rotator week 6 cuff and deltoid strengthening. Active assisted ROM for improving ROM

•H igh-grade glenohumeral mobilizations and shoulder PROM

Abbreviations: AC, acromioclavicular; PROM, passive range of motion; ROM, range of motion; SC, sternoclavicular.

pain. The patient’s score on the SPADI completed at this session was 38 points, which represented a 17-point improvement. Her score on the QuickDASH improved to 23 points, for a 45-point improvement. In addition to these 2 selfreport outcome measures, the global rating of change (GRC) score was used to quantify the patient’s perceived improvement or deterioration. The GRC has been shown to have good test-retest reliability (intraclass correlation coefficient of 0.90).10 The GRC consists of a 15-point Likert scale ranging from –7 to +7, with

higher positive scores indicating greater perceived improvements. The patient’s GRC score was +5, indicating quite a bit better and a clinically meaningful change since baseline.22,31 At this time, the patient’s primary functional limitation was the inability to don or doff a bra. During this session, exercises aiming to increase circulation and improve strength were performed (TABLE 2). Seated thrust manipulation of the cervicothoracic and midthoracic spine was continued with the goal of pain modulation. Glenohumeral mobilizations were



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8

7

6

5


Baseline

SPADI

Session 5

Final Session

Rating

Points

80 70 60 50 40 30 20 10 0

QuickDASH

FIGURE 2. Scores on the SPADI and QuickDASH over the course of treatment, which consisted of 13 sessions over a 6-week period. Both the SPADI and the QuickDASH have a maximum score of 100, a lower score representing better function. Abbreviations: QuickDASH, shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire; SPADI, Shoulder Pain and Disability Index.

initiated secondary to improved tolerance to the treatment. Dry needling was then performed in the same manner as the previous 2 sessions, targeting the trigger points associated with the upper trapezius, levator scapula, infraspinatus, and deltoid. Following dry needling, passive ROM exercises were performed for shoulder flexion, abduction, and external rotation. The patient was able to tolerate the ends of passive range, with 3/10 pain on the NPRS reported. Active shoulder ROM was not measured during this session. Treatment Session 6 The patient reported that her pain level after the previous treatment and at rest was 2/10 on the NPRS. This pain was described as unfamiliar muscle soreness in the upper trapezius and deltoid, in the areas where dry needling was performed. However, she was able to reach higher up her back, although not to the level of being able to don or doff a bra. Exercise activity and manual therapy interventions were unchanged. The deltoid muscle group had a palpable trigger point that reproduced the shoulder pain that was described by the patient during this visit. Dry needling of the deltoid muscle group was performed, but not of the upper trapezius and infraspinatus, secondary to these muscles lacking trigger points that elicited a familiar pain. Although painfree ROM of reaching behind the back

4

3

2

1

0 Baseline

Session 2

Session 3

Session 4

Session 5

Session 6

Sessions 8-13

FIGURE 3. Pain rating at rest using an 11-point numeric pain rating scale, where 0 is no pain and 10 is the worst pain imaginable.

improved, the therapist was only able to achieve 140° of passive shoulder flexion and 130° of passive shoulder abduction. Treatment Sessions 7 and 8 The patient still had her chief concern of pain with reaching behind her back. Her resting and activity-related pain was 0/10 and 2/10, respectively. It was determined that the patient had gained maximum pain modulation from dry needling and thrust manipulation. The focus of these 2 treatment sessions was on higher-grade (III and IV) mobilization techniques directed at the glenohumeral joint. The decision to incorporate these into the treatment at this point was based on the improved pain level and tolerance to glenohumeral joint mobilizations. Following treatment, internal rotation of the left shoulder, measured without scapular stabilization, improved to 85° at 90° of abduction. A towel internal-rotation stretch was provided for her home exercise program. Treatment Sessions 9 to 13 The focus of the final sessions was higher-grade joint mobilization and passive ROM activities. Because the patient was able to tolerate end of range with less pain and pain abatement when out of position, the passive ROM treatment and exercises could be more aggressive. In addition, the

home exercise program was transitioned from a pain-modulation focus to one that emphasized gains in ROM. The program also included isotonic shoulder exercises for strengthening the rotator cuff and scapulothoracic muscle groups. The home exercise program included active assisted ROM into flexion, abduction, and internal and external rotation. ROM and pain reduction gains in the previous sessions were maintained throughout the remainder of care. Function continued to improve, as reflected by significantly better scores on the QuickDASH and SPADI self-report questionnaires.

OUTCOMES

T

his patient was seen for 13 treatment sessions over a 6-week period and demonstrated clinically meaningful improvements in all measured outcomes. Scores on the 2 primary outcome measures, the SPADI and QuickDASH questionnaires, are displayed in FIGURE 2. The score of the SPADI went from 55 at baseline to 38 at the fifth treatment session to 5 at discharge. This represents a 50-point improvement, which far exceeds the 8- to 13-point MCID for the SPADI.35 Similarly, the pa-



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[

case report

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120

provements correlate well with improvements in the scores on the self-report outcome measures, as well as activities of reaching the top of her head to wash her hair and reaching behind her back to don and doff a bra.

100

DISCUSSION

180 160

T

80 60 40 Baseline

Session 2

Session 4

Session 6

Shoulder flexion

Session 8

Session 10

Session 11

Session 13

Shoulder abduction

FIGURE 4. Passive shoulder flexion and abduction range of motion over the course of treatment, which consisted of 13 sessions over a 6-week period.

100 90 80 70 60

Degrees


Degrees

140

50 40 30 20 10 0 Baseline

Session 2

Session 4

Session 8

Internal rotation

Session 11

Session 13

External rotation

FIGURE 5. Passive shoulder internal and external rotation range of motion over the course of treatment, which consisted of 13 sessions over a 6-week period.

tient had a 43-point improvement on the QuickDASH score by the fifth treatment session (baseline, 68; fifth session, 25), and at discharge the QuickDASH score was 7 points. This, again, far exceeded the 8-point MCID for this outcome measure both at the fifth visit and at discharge.31 These changes are consistent with the patient reporting a GRC of +5, indicating quite a bit better, by the fifth visit.22 GRC was not assessed at discharge.

Pain, as assessed using the NPRS, decreased from 8/10 with activity and 4/10 at rest during the initial examination to 2/10 with activity and 0/10 at rest at discharge. For patients with shoulder pain, the MCID for the NPRS has been reported to be 2.17.29 Changes in resting pain assessed using the NPRS are illustrated in FIGURE 3. Improvements in shoulder ROM are illustrated in FIGURES 4 and 5. These im-

he purpose of this case report was to describe the clinical reasoning and outcomes using dry needling as part of a plan of care for a patient with adhesive capsulitis. Early interventions in this case were performed to reduce the patient’s pain. A regionalinterdependence approach that included thrust manipulation techniques to the thoracic and cervicothoracic regions, and thoracic and cervicothoracic techniques, was initially performed. Thrust manipulation of the cervicothoracic region has been shown to be effective in modulating pain in patients with neck and shoulder problems.4,30,39 There is evidence for those with shoulder pain associated with subacromial impingement syndrome that a cervicothoracic-directed thrust manipulation may provide some benefit, including pain reduction and improved mobility.4,30 However, these interventions have not been tested on patients with adhesive capsulitis, and the patient described in this case had limited improvement using this approach. It was determined that the pain the patient was experiencing was due in part to trigger points located in the upper trapezius, levator scapula, deltoid, and infraspinatus muscles. After these trigger points were treated with dry needling, the patient had significant improvements in ROM and perceived disability on the QuickDASH and SPADI self-report questionnaires. Although adhesive capsulitis is thought to be primarily a disorder affecting the joint capsule, it is possible that neuromotor abnormalities contribute to the pain, including the development of trigger points in the muscles of the scapulothoracic region. Pain and associated



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ROM impairments may be due in part to these developed trigger points, especially in later stages of adhesive capsulitis. Preliminary evidence suggests that dry needling can both modulate pain11,14,18 and decrease aberrant motor activity.17 The additional improvements seen in this patient after dry needling might have been due to a decrease in pain, which allowed more shoulder ROM. The clinical course of adhesive capsulitis has been well described as a continuum of 4 stages.23,32 Stage 1 lasts up to 3 months and is characterized by sharp pain at the end of available motion, achy pain at rest, and sleep disruption.23 Early loss of external rotation ROM is also seen in this stage.23 Stage 2 lasts from 3 to 9 months and is characterized by a gradual loss of motion in all directions due to pain.23,32 Stage 3 lasts from 9 to 15 months and is characterized by lessened synovitis/angiogenesis with progressive fibrosis, which results in a loss of the axillary fold to further limit ROM.23,32 Stage 4 lasts from 15 to 24 months and is characterized by pain resolution and improved motion, although some ROM restriction may persist.23,32 The patient’s shoulder condition described in this case best matched a stage 2 presentation. Although adhesive capsulitis is considered to involve primarily the capsular tissue,1,3,6,25 the pain the patient experienced was most likely due to myofascial trigger points, indicating that the synovitis stage had resolved. Furthermore, significant gains in ROM after the pain was reduced suggest that capsule fibrosis, which is characteristic of stage 3, had likely not developed. While the exact mechanism of dry needling is still being debated, a recent systematic review and meta-analysis by Kietrys et al24 showed that dry needling is an effective intervention when compared to a sham or placebo treatment for reducing pain associated with myofascial pain syndromes. This patient had significant pain reproduced from palpation of the associated myofascial trigger points. Dry needling might have directly affected the

patient’s pain experience associated with the myofascial trigger points. A comparison of the effects of dry needling on shoulder ROM, pain, and pressure pain threshold in the surrounding shoulder muscles was done in a randomized controlled trial by Hsieh et al.18 The study included 14 subjects from a pain clinic who presented with bilateral nonspecific shoulder pain and bilateral myofascial trigger points of the infraspinatus muscle. Subjects received dry needling to the infraspinatus muscle until an LTR was elicited on 1 side, while the contralateral side received no treatment. Significant changes were noted in the side that was treated with dry needling for the measures of pain, pressure pain threshold, and shoulder active and passive internal rotation ROM. The control side did not demonstrate any significant changes in any of the measures. Limitations to the Hsieh et al18 study were the small sample size and the lack of a pure control group or a comparison group. However, results from the Hsieh et al18 study suggest an effect on shoulder ROM, which is consistent with the results from this case report. Although it is common to initiate early treatment directed at the glenohumeral joint, including low-grade (I and II) mobilizations, this was not performed on this patient.23 This clinical decision was based on the patient’s high levels of pain experienced with hypomobility and evidence supporting regional interdependence in other shoulder conditions, specifically interventions targeting the cervicothoracic spine for reduction of pain.4,30,39 This is a potential limitation of the case because it is not consistent with current clinical practice guidelines.23 However, because the glenohumeral joint was not treated with graded mobilization, coupled with the limited effectiveness of cervicothoracic and thoracic thrust techniques, the decreased pain the patient experienced was more likely related to dry needling. The findings from this case report are promising. The clinical course of this case indicates that dry needling may be most

effective when trigger points are identified as a primary source of the pain and when the synovitis stage has resolved. However, because it is a single case report, cause and effect and generalizability cannot be inferred. A larger case series demonstrating the use of dry needling as a component of treatment for those who do not respond within the first 3 sessions of physical therapy, including manual physical therapy, would provide insight into the effectiveness of the intervention as an adjunct to care. Higher-level research should compare groups that receive dry needling as a component of their rehabilitation for adhesive capsulitis to those that do not.

CONCLUSION

T

his case report described the clinical reasoning and treatment of a patient with adhesive capsulitis using dry needling as a component of the plan of care. The outcomes showing significant improvement in shoulder ROM, pain, and function, especially after the addition of dry needling, suggest a potential benefit of this intervention in patients with this condition. Further research needs to be performed in patients with adhesive capsulitis, controlling for dry needling as a primary intervention, before conclusions can be inferred regarding the effectiveness of this approach. t

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