肩周炎 JIAN ZHOU YAN - FROZEN SHOULDER

TRADITIONAL CHINESE MEDICINE PERSPECTIVE

Bi means obstruction or blockage. Bi pattern describes a set of patterns in which the invasion of external evils such as wind, cold, dampness and heat obstruct the flow of Qi and Blood through the channels and connections. This affects the muscles, bones, tendons and joints, presenting symptoms of aching, pain, heaviness, numbness, difficulty of movement or redness and swelling. Bi patterns include several disorders known in Western medicine as osteoarthritis, rheumatoid arthritis, rheumatic fever, fibrosis, gout, sciatica, and frozen shoulder.

Frozen shoulder, medically referred to as adhesive capsulitis, is an inflammation characterized by stiffness and chronic pain in the shoulder joint and loss of range of motion in the rotator cuff region; arm movements become difficult and the frozen shoulder interferes with a peaceful night’s sleep. During the 20th century the Chinese coined the term 50-years shoulder or Wushi Jian, referring to the typical age of onset of the disorder and this is how the ailment is known in China, but the term Jianbang, or frozen shoulder, is also used. While there are numerous references to traditional style Chinese medical treatments for problems of the shoulder area, investigations into the use of the therapies specifically aimed at frozen shoulder have only been described in the last few years.

The clinical manifestation of frozen shoulder is shoulder pain. At the beginning stage, the pain is intermittent, worse at night. Gradually the pain becomes severe and constant. Climate change or fatigue can aggravate the pain. Movement of the shoulder is severely restricted in all directions, typically stretching, upholding, pronation, and supination. It is difficult to accomplish many daily activities, such as combing, wearing clothes, and washing the face. Patients are especially sensitive to cold air and cool wind. Certain diseases increase the incidence of frozen shoulder, especially diabetes and thyroid diseases. Injuries are a common cause of frozen shoulder; for therapeutic purposes this condition should be distinguished from other injuries causing shoulder stiffness and pain, such as a torn rotator cuff.

Frozen shoulder is called “Shoulder attacked by wind” in Chinese medicine. It is usually caused by a weak body constitution, insufficiency of liver and kidney essence, deficiency of Qi and Blood, insufficient nourishment of tendon and bone, plus exhaustion, invasion of external wind and cold that disturb the flow of Qi in the meridians. These can affect the flow of Qi and blood in the channels of the shoulder, with obstruction leading to pain. Gradually the tendons adhere, and motion is restricted.

In Chinese medicine, Frozen Shoulder falls under the category of Bi Zheng or Bi Pattern. Bi means obstruction or blockage. Bi pattern describes a set of patterns in which the invasion of external evils such as wind, cold, dampness and heat obstruct the flow of Qi and Blood through the channels and connections. This affects the muscles, bones, tendons and joints, presenting symptoms of aching, pain, heaviness, numbness, difficulty of movement or redness and swelling. Bi patterns include several disorders known in Western medicine and among them is frozen shoulder.

Etiology and Pathogenesis

The etiology of bi patterns usually combines an internal or preexisting deficiency of correct Qi with external evils entering the body: wind, cold, damp or heat. Simultaneous invasion by wind, cold and damp is the most common. Bi patterns are considered in four classes based on the specific external evil and the differing clinical manifestations. Bi patterns involve LV, SP and KD. LV controls tendon, SP controls muscles, and KD controls bones.

1.Wind bi or feng bi, also known as wandering bi Xing bi, is characterized by wind evil with pain roving through various locations. Major pain in joints.

2.Cold bi han bi, also known as painful bi Tong bi, is characterized by the accumulation of cold with severe pain in the channels.

3.Damp bi ji bi, also known as fixed bi Zhao bi, is characterized by the accumulation of dampness with muscular and joint numbness, aching, heaviness, swelling and pain of fixed location.

4.Heat bi re bi, is characterized by fever and red, swollen, and painful joints. Its causes include invasion by heat evil; untreated and chronic Wind-Cold-Dampness-bi that has transformed into heat; or constitutions of either profuse Yang or deficient Yin, that have transformed external evils to heat.

All bi patterns involve obstruction of the channels and connections inhibiting the flow of Qi and Blood. Chronic cases of bi, regardless of a particular evil’s dominance, present three major categories of pathological change.

The first includes manifestations of blood-stasis and phlegm-turbidity such as stasis macules on the tongue, nodes in the area of affected joints and swelling, and difficulty moving the joints.

The second involves symptoms of deficient Qi and Blood. The severity will vary according to the injury and depletion of Qi and Blood during the illness.

The third includes pathological changes from the progress of evils from the channels and connections into the viscera and bowels. Most commonly observed is heart beat with palpitations, cyanosis, asthma, and edema.

FREE PEARLS: 1) KD will always be secondary symptom, 2) Wind, Heat, and Blood Stasis should be treated with distal points; and Qi and Blood Deficiency with local points.

TCM Patterns

Wind-Dominant Bi
Heat-Dominant Bi
Bi with Blood Stasis and Phlegm-Turbidity

1.Wind-Dominant Bi

Symptoms
Roaming pain in the joints and limbs, pain of indeterminate locations, difficulty in flexion and extension of joints, aversion to cold and in some cases, fever.
Tongue: Thin white coating.
Pulse: Wiry, floating.
Treatment Strategy:
Dispel wind, clear the connections, dissipate cold, and drain dampness. For wind problems treat blood first with UB17 and SP10, then needle the rest.

2.Heat-Dominant Bi

Symptoms: Severe pain, local heat, redness and swelling; difficulty of movement affecting one or more joints accompanied with fever, sore throat, thirst, irritability and dark, scanty urine.
Tongue: Yellow coating.
Pulse: Rapid, slippery.
Treatment Strategy: Drain heat, clear the connections, dispel wind, drain dampness.

3.Bi with Blood Stasis and Phlegm-Turbidity

Symptoms: In each of the above bi patterns, chronic illnesses that have not been properly treated lead to blood stasis and phlegm-turbidity. This blocks the channels, connections and joints. Symptoms include swelling, stiffness and deformity of the joints, incessant pain and complete immobility.
Tongue: Dark or purple, with white slimy coating.
Pulse: Deep-rough, or deep-slippery.
Treatment Strategy: Dispel stasis, transform phlegm, free the connections, relieve pain.

ACUPUNCTURE WITH DISTAL POINTS
One of the earliest Chinese reports of acupuncture treatment of frozen shoulder was published in 1991,^[3] based on a simple treatment method. The author of the article, Zhang Maohai, claimed to have found an effective therapy through his experiences. He focused on one acupuncture point, YANGLINGQUAN GB34, located on the leg, which he said seemed more effective than treating multiple points. The point was needled on one side only, the same side as the affected shoulder. In rare cases where this same side treatment did not seem to be helpful, the point was needled on the other leg instead.

The selection of this acupuncture point is of interest. Traditionally, YANGLINGQUAN GB34 is mainly indicated for treatment of lower limb disorders, such as pain and numbness in the legs and knees, but the effects of stimulating this point are thought to also extend upward along the gallbladder meridian, which traverses the costal region to the shoulder. There, the meridian passes through the point JIANJING GB21, indicted for stiffness of the neck, pain of the shoulder and upper back, and for difficulty moving the arm. A further basis for using GB34 is its reputation for soothing and moistening the sinews. Since the shoulder capsule is contracted, this action is considered important to healing the disorder.

In 1993 Lü Jingshan described how YANGLINGQUAN GB34 is a valuable acupuncture point for the treatment of pain of the shoulder, elbow, costal region, lower back, and knee.^[4] Regarding shoulder pain, Lü wrote:

Shoulder pain is most often due to periarthritis of shoulder or injury to soft tissues due to invasion of wind and cold, or damage to channels or tendons that obstruct passage of Qi and blood and result in pain. Following the principle of ‘malady above treated by selecting relevant acupoints below, the author treated pain in the shoulder by acupuncture at YANGLINGQUAN GB-34 with fairly satisfactory results, particularly in cases of short duration or caused by contusion or sprain.

He described a treatment strategy similar to that outlined above, with 30 minute needle retention and stimulus at the beginning and then at intervals ─but, in this case, 10 minute intervals, while the patient exercised the shoulders. Application of acupuncture to YANGLINGQUAN GB34 on the side opposite the affected shoulder was used by another group, who reported on several successful uses of contralateral therapy.^[5]

A similar method was described in a report by Feng Zhengen,^[6] using the extra point LINGXIA, located 2 cun below YANGLINGQUAN GB34. The point was needled ipsilaterally, or on the same side as the affected shoulder, while SANJIAN LI-3, on the hand, was needled on the opposite side. The patient would move the affected arm during the acupuncture therapy. Treatment was given daily for 10 sessions, followed by a 2 day break and then another 10 sessions. It was reported that of 210 patients treated, 158 cases were resolved, and that all but 12 cases showed some improvement. The selection of LINGXIA, rather than YANGLINGQUAN GB34 was based, according to the author, on the fact that he found a marked tender point at this spot which, when pressed, alleviated the shoulder pain.

BIOMEDICAL PERSPECTIVE ON FROZEN SHOULDER

Biomedicine uses imaging tests such as x-rays, MRIs, and range of motion tests to diagnose frozen shoulder.

TREATMENT
Below are sketches showing shoulder exercises. Most frozen shoulder treatment involves controlling shoulder pain and preserving as much range of motion in the shoulder as possible. Western medicine usually treats frozen shoulder with anti-inflammatory drugs, physical/occupational therapy, injection of steroids into shoulder joint, and surgery.

MEDICATIONS
Over-the-counter pain relievers, such as aspirin and ibuprofen (Advil, Motrin IB, others), can help reduce pain and inflammation associated with frozen shoulder. In some cases, your doctor may prescribe stronger pain-relieving and anti-inflammatory drugs.

THERAPY
A physical therapist can teaches range-of-motion exercises to help recover as much shoulder mobility as possible. Commitment from the patient is imperative to optimize recovery of mobility.

SURGICAL AND OTHER PROCEDURES
Most frozen shoulders get better on their own within 12 to 18 months. For persistent symptoms, doctors may suggest:
Steroid injections: Injecting corticosteroids into the shoulder joint may help decrease pain and improve shoulder mobility, especially in the early stages of the process.
Joint distension: Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.
Shoulder manipulation: In this procedure, the patient receives a general anesthetic, so to be unconscious and feel no pain. Then the doctor moves the shoulder joint in different directions, to help loosen the tightened tissue.

Surgery for frozen shoulder is rare, but if nothing else has helped, the doctor may recommend surgery to remove scar tissue and adhesions from inside the shoulder joint. Doctors usually perform this surgery with lighted, tubular instruments inserted through small incisions around the joint (arthroscopically).

LIFESTYLE AND HOME REMEDIES
Continue to use the involved shoulder and extremity as much as possible given the pain and range-of-motion limits. Applying heat or cold to the shoulder can help relieve pain.

FOLLOWING ARE 7 EXERCISES TO EASE THE PAIN OF FROZEN SHOULDER_[2]

Pendulum Stretch: Do this exercise first. Relax your shoulders. Stand and lean over slightly, allowing the affected arm to hang down. Swing the arm in a small circle — about a foot in diameter. Perform 10 revolutions in each direction, once a day. As your symptoms improve, increase the diameter of your swing, but never force it. When you’re ready for more, increase the stretch by holding a light weight (three to five pounds) in the swinging arm.

Towel Stretch: Hold one end of a three-foot-long towel behind your back and grab the opposite end with your other hand. Hold the towel in a horizontal position. Use your good arm to pull the affected arm upward to stretch it. You can also do an advanced version of this exercise with the towel draped over your good shoulder. Hold the bottom of the towel with the affected arm and pull it toward the lower back with the unaffected arm. Do this 10 to 20 times a day.

Finger Walk: Face a wall three-quarters of an arm’s length away. Reach out and touch the wall at waist level with the fingertips of the affected arm. With your elbow slightly bent, slowly walk your fingers up the wall, spider-like, until you’ve raised your arm as far as you comfortably can. Your fingers should be doing the work, not your shoulder muscles. Slowly lower the arm (with the help of the good arm, if necessary) and repeat. Perform this exercise 10 to 20 times a day.

Cross-Body Reach: Sit or stand. Use your good arm to lift your affected arm at the elbow, and bring it up and across your body, exerting gentle pressure to stretch the shoulder. Hold the stretch for 15 to 20 seconds. Do this 10 to 20 times per day.

Armpit Stretch: Using your good arm, lift the affected arm onto a shelf about breast-high. Gently bend your knees, opening up the armpit. Deepen your knee bend slightly, gently stretching the armpit, and then straighten. With each knee bend, stretch a little further, but don’t force it. Do this 10 to 20 times each day.

Starting to strengthen
As range of motion improves, rotator cuff–strengthening exercises should be added. Warm up of the shoulder and stretching exercises before performing strengthening exercises are imperative.

Outward Rotation: Hold a rubber exercise band between your hands with your elbows at a 90-degree angle close to your sides. Rotate the lower part of the affected arm outward two or three inches and hold for five seconds. Repeat 10 to 15 times, once a day.

Inward Rotation: Stand next to a closed door, and hook one end of a rubber exercise band around the doorknob. Hold the other end with the hand of the affected arm, holding your elbow at a 90-degree angle. Pull the band toward your body two or three inches and hold for five seconds. Repeat 10 to 15 times, once a day.

 

MISCELLANEOUS AILMENTS

TREATMENTS OFFERED

__________________________________________________________________________________________________________________________________________________________________REFERENCES
^[1]Personal classroom notes. 2005-2011.
^[2]Harvard Health Publishing. Harvard Medical School. https://www.health.harvard.edu/shoulders/stretching-exercises-frozen-shoulder. Retrieved July 16th, 2020.
^[3]Zhang Maohai, Treatment of periomarthritis with acupuncture at yanglingquan (GB-34), Journal of Traditional Chinese Medicine 1991; 11(1): 9-10.
^[4]Lü Jingshan, The clinical application of yanglingquan (GB-34) point, Journal of Traditional Chinese Medicine 1991; 13(3): 179-181.
^[5]Liu G and Wang S, Needling at contralateral yanglingquan in treatment of shoulder periarthritis: report of 115 cases, International Journal of Clinical Acupuncture, 1993; (4): 297-300.
^[6]Feng Zhengen, 210 cases of shoulder periarthritis treated by needling lingxia and sanjian, Journal of Traditional Chinese Medicine 2003; 23(3): 201-202.

-Above Article Written by Dr. Osorio, Gloria DAOM, L.Ac. 2020.