Frozen Shoulder

Epaule gelée : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture.
☆☆ Evidence for effectiveness of acupuncture.
Evidence for effectiveness of acupuncture mais limitées qualitativement et/ou quantitativement.
Ø No evidence or insufficient evidence.

1.1. Generic Acupuncture

1.1.1. Ben-Arie 2020

Ben-Arie E, Kao PY, Lee YC, Ho WC, Chou LW, Liu HP. The Effectiveness of Acupuncture in the Treatment of Frozen Shoulder: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2020. [212695]. doi

BackgroundFrozen shoulder (FS) is associated with pain, reduced range of motion (ROM), and shoulder function. The condition occurs in 2-5% of the population, and it is especially common around the age of 50 years. FS symptoms will recover after 1-4 years. Many patients turn to acupuncture in order to alleviate the FS symptoms.
Objective In this review, we will investigate the efficiency of acupuncture as a FS treatment.
Methods A literature search of acupuncture and FS-related keywords was performed in the following databases: PubMed, Cochrane Library, Embase, and Web of Science. Thirteen publications were included for a systematic review, and a meta-analysis was done using the following measurements: visual analogue scale (VAS) for pain, Constant-Murley Shoulder Outcome Score (CMS) for shoulder function, and active shoulder ROM including flexion, abduction, and external rotation. The Cochrane Collaboration's risk of bias tool and quality of evidence GRADE recommendations and STRICTA 2010 were used to grade the included publications.
ResultsA meta-analysis on VAS pain score showed significant pain reduction, restoring CMS shoulder function, and flexion ROM in favor of acupuncture versus the control. In external rotation and abduction ROM, a meta-analysis was not significant. The most used acupoints are Jian Yu (LI15) and Jian Liao (TB14).
ConclusionsThe results indicate that acupuncture could be safe and effective for pain reduction, restoring shoulder function, and restoring flexion ROM for FS patients in the short term and midterm. However, the level of evidence was very low. More high-quality and longer studies are needed in order to robust the evidence. Jain 2014 ★★

Jain TK, Sharma NK. The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: a systematic review. J Back Musculoskelet Rehabil. 2014;27(3):247-73. [179470].

Background And ObjectiveFrozen shoulder is a common condition, yet its treatment remains challenging. In this review, the current best evidence for the use of physical therapy interventions (PTI) is evaluated.
MethodMEDLINE, CINAHL, Cochrane, PEDro, ProQuest, Science Direct, and Sport Discus were searched for studies published in English since 2000.
Results39 articles describing the PTI were analyzed using Sackett's levels of evidence and were examined for scientific rigor. The PTI were given grades of recommendation that ranged from A to C.
ConclusionsTherapeutic exercises and mobilization are strongly recommended for reducing pain, improving range of motion (ROM) and function in patients with stages 2 and 3 of frozen shoulder. Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function but not recommended for improving ROM. Corticosteroid injections can be used for stage 1 frozen shoulder. Acupuncture with therapeutic exercises is moderately recommended for pain relief, improving ROM and function. Electro-therapy can help in providing short-term pain relief. Continuous passive motion is recommended for short-term pain relief but not for improving ROM or function. Deep heat can be used for pain relief and improving ROM. Ultrasound for pain relief, improving ROM or function is not recommended.

1.1.2. Maund 2012 ∅

Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, Mcdaid C. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2012. 16(11):1-264. [166056].

BackgroundFrozen shoulder is condition in which movement of the shoulder becomes restricted. It can be described as either primary (idiopathic) whereby the aetiology is unknown, or secondary, when it can be attributed to another cause. It is commonly a self-limiting condition, of approximately 1 to 3 years' duration, though incomplete resolution can occur.
ObjectivesTo evaluate the clinical effectiveness and cost-effectiveness of treatments for primary frozen shoulder, identify the most appropriate intervention by stage of condition and highlight any gaps in the evidence. DATA SOURCES: A systematic review was conducted. Nineteen databases and other sources including the Cumulative Index to Nursing and Allied Health (CINAHL), Science Citation Index, BIOSIS Previews and Database of Abstracts of Reviews of Effects (DARE) were searched up to March 2010 and EMBASE and MEDLINE up to January 2011, without language restrictions. MEDLINE, CINAHL and PsycINFO were searched in June 2010 for studies of patients' views about treatment.
Review methods Randomised controlled trials (RCTs) evaluating physical therapies, arthrographic distension, steroid injection, sodium hyaluronate injection, manipulation under anaesthesia, capsular release or watchful waiting, alone or in combination were eligible for inclusion. Patients with primary frozen shoulder (with or without diabetes) were included. Quasi-experimental studies were included in the absence of RCTs and case series for manipulation under anaesthesia (MUA) and capsular release only. Full economic evaluations meeting the intervention and population inclusion criteria of the clinical review were included. Two researchers independently screened studies for relevance based on the inclusion criteria. One reviewer extracted data and assessed study quality; this was checked by a second reviewer. The main outcomes of interest were pain, range of movement, function and disability, quality of life and adverse events. The analysis comprised a narrative synthesis and pair-wise meta-analysis. A mixed-treatment comparison (MTC) was also undertaken. An economic decision model was intended, but was found to be implausible because of a lack of available evidence. Resource use was estimated from clinical advisors and combined with quality-adjusted life-years obtained through mapping to present tentative cost-effectiveness results.
ResultsThirty-one clinical effectiveness studies and one economic evaluation were included. The clinical effectiveness studies evaluated steroid injection, sodium hyaluronate, supervised neglect, physical therapy (mainly physiotherapy), acupuncture, MUA, distension and capsular release. Many of the studies identified were at high risk of bias. Because of variation in the interventions and comparators few studies could be pooled in a meta-analysis. Based on single RCTs, and for some outcomes only, short-wave diathermy may be more effective than home exercise. High-grade mobilisation may be more effective than low-grade mobilisation in a population in which most patients have already had treatment. Data from two RCTs showed that there may be benefit from adding a single intra-articular steroid injection to home exercise in patients with frozen shoulder of < 6 months' duration. The same two trials showed that there may be benefit from adding physiotherapy (including mobilisation) to a single steroid injection. Based on a network of nine studies the MTC found that steroid combined with physiotherapy was the only treatment showing a statistically and clinically significant beneficial treatment effect compared with placebo for short-term pain (standardised mean difference -1.58, 95% credible interval -2.96 to -0.42). This analysis was based on only a subset of the evidence, which may explain why the findings are only partly supportive of the main analysis. No studies of patients' views about the treatments were identified. Average costs ranged from £36.16 for unguided steroid injections to £2204 for capsular release. The findings of the mapping suggest a positive relationship between outcome and European Quality of Life-5 Dimensions (EQ-5D) score: a decreasing visual analogue scale score (less pain) was accompanied by an increasing (better) EQ-5D score. The one published economic evaluation suggested that low-grade mobilisation may be more cost-effective than high-grade mobilisation. Our tentative cost-effectiveness analysis suggested that steroid alone may be more cost-effective than steroid plus physiotherapy or physiotherapy alone. These results are very uncertain. Three studies compared acupuncture with another treatment, although only one provided data beyond 4 weeks’ follow-up. This study had a potentially high risk of bias and it was unclear whether it had enough participants to detect a difference between groups. Based on a single study, there was no statistically significant difference between electroacupuncture and inferential electrotherapy in pain or function and disability at short-, medium- or long-term follow-up. There was insufficient evidence to make conclusions with any certainty about the effectiveness of acupuncture for primary frozen shoulder and in what situations it is likely to be effective.
Limitations The key limitation was the lack of data available. It was not possible to undertake the planned synthesis exploring the influence of stage of frozen shoulder or the presence of diabetes on treatment effect. As a result of study diversity and poor reporting of outcome data there were few instances where the planned quantitative synthesis was possible or appropriate. Most of the included studies had a small number of participants and may have been underpowered. The lack of available data made the development of a decision-analytic model implausible. We found little evidence on treatment related to stage of condition, treatment pathways, the impact on quality of life, associated resource use and no information on utilities. Without making a number of questionable assumptions modelling was not possible.
Conclusions There was limited clinical evidence on the effectiveness of treatments for primary frozen shoulder. The economic evidence was so limited that no conclusions can be made about the cost-effectiveness of the different treatments. High-quality primary research is required.

1.1.3. Murphy 2010 Ø

Murphy RJ, Carr AJ. Shoulder pain. BMJ Clin Evid. 2010;pii: 1107. [164600] .

Introduction Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases.
Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment, topical drug treatment, local injections, non-drug treatment, and surgical treatment? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound.
Acupuncture Unknown effectiveness.

1.1.4. Favejee 2010 ★

Favejee MM, Huisstede BM, Koes BW. Frozen Shoulder: The effectiveness of conservative and surgical interventions–systematic review. Br J Sports Med. 2010;JUL 20. [154142]

Purpose A variety of therapeutic interventions is available for restoring motion and diminishing pain in patients with frozen shoulder. An overview article concerning the evidence for the effectiveness of these interventions is lacking. Objective To provide an evidence-based overview regarding the effectiveness of conservative and surgical interventions to treat the frozen shoulder.
Methods The Cochrane Library, PubMed, Embase, Cinahl and Pedro were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently selected relevant studies, assessed the methodological quality and extracted data. A best-evidence synthesis was used to summarise the results.
Results Five Cochrane reviews and 18 RCTs were included studying the effectiveness of oral medication, injection therapy, physiotherapy, acupuncture, arthrographic distension and suprascapular nerve block (SSNB)..
Conclusion We found strong evidence for the effectiveness of steroid injections and laser therapy in short-term and moderate evidence for steroid injections in mid-term follow-up. Moderate evidence was found in favour of mobilisation techniques in the short and long term, for the effectiveness of arthrographic distension alone and as an addition to active physiotherapy in the short term, for the effectiveness of oral steroids compared with no treatment or placebo in the short term, and for the effectiveness of SSNB compared with acupuncture, placebo or steroid injections. For other commonly used interventions no or only limited evidence of effectiveness was found. Most of the included studies reported short-term results, whereas symptoms of frozen shoulder may last up to 4 years. High quality RCTs studying long-term results are clearly needed in this field.
Acupuncture moderate evidence was found for the effectiveness of […] for acupuncture […] in addition to exercises.

1.1.5. Peng 2007 ★

Peng Wn et al. Review of acupuncture for frozen shoulder. World J Acu-moxi. 2007;17(2):1-15.[151993]

Purpose To assess the efficacy and possible adverse effects of acupuncture on frozen shoulder.
Methods Based on the key words, i.e. acupuncture, electroacupuncture, acupuncture-moxibustion, frozen shoulder, adhesive capsulitis, shoulder disorders etc., the Chinese databases were retrieved, including Cochrane Musculoskeleta Group, Cochrane Controlled Trials Register, Cochrane Complementary Medicine Field, and the central database of the Cochrane Library as weil as MEDLINE, EMBASE and Chinese Biomedical CD ( CBM-disc). 20 Chinese medical journals and relevant academic conference proceedings have been searched manually
Results 6 randomized controlled trials (608 patients) on frozen shoulder with acupuncture and electroacupuncture were included, indicating quite advanced study quality. The total odds ratio (OR) of CMS/CSA was OR 3.49 ( 95% Cl-2.64 to 9.63), the total OR of VAS was OR -1.24 (95% Cl -3.50 to 1.01), the total OR of ROM was OR 35.70 (95% Cl 22.91 to 48.49); the total OR of MELLE was OR 4. 30 (95% Cl 2. 32 to 7. 98).
Conclusion lt is shawn in the present limited inclusive trials on frozen shoulder that acupuncture is the safe therapy and effective on improving the global function, relieving pain, and improving the range of motion of shoulder. All the therapeutic effects of acupuncture are superior to those in control group. However, much more high quality trials are required to provide much stronger evidence.

1.2. Special Acupuncture Techniques

1.2.1. Triple puncture Tang 2015 ★

Tang Hongliang, Lu Dongming, Li Liqun, Zhu Yuanyuan, Xuan Chuanfeng, Tan Liling, Chen Ting, Pang Jun. [A Systematic review on clinical study of the frozen shoulder treated with three shoulder needles]. Liaoning Journal of Traditional Chinese Medicine. 2015;5: 933-936. [187037].

ObjectiveTo systematically review the clinical study of the frozen shoulder treated with three shoulder needles.
MethodsThe Chinese databases were electronically retrieved, including Cochrane Library, Wan Fang Data, CNKI and VIP. According to the inclusion and exclusion criteria, five reviewers screened literature, and extracted the effective data based on the evaluative standard of Cochrane systematic data, and assessed the methodological quality. And then analyze the therapeutic effect with the Review Manage 5. 0 software.
ResultsWe included 5 identified documents and 5 randomized controlled trials in total, including 449 participants. The Meta- analysis result showed that the total effective rate and the curative rate of three shoulder needles group were higher than that of the control group with statistical significance respectively [RR: 2. 92, 95% CI (1. 13, 7. 56); RR: 2. 35, 95% CI (1. 52, 3. 63)].
Conclusio Current evidence shows that the therapeutic effect of frozen shoulder treated with three shoulder needles is effective. However, more high quality studies with large sample size and long term follow- up are still needed to verify the above conclusion because of the limited quantity and quality of the included studies.

1.2.2. Acupotomy Ma 2014

Ma Shining, Shang Qinghua, Fu Daerling, Luo Zhichao. [Systematic review on comparing blockage and acupotomology in treating frozen shoulder]. World Chinese Medicine. 2014;9(3):361-4. [168737].

ObjectiveTo evaluate the clinical safety and efficacy of blockage and acupotomology for frozen shoulder.
MethodsRandomized controlled trials ( RCTs) on blockage and acupotomology in the treatment of frozen shoulder were retrieved from CBM ( from year 1978 to 2013), CNKI (from year 1979 to 2013), VIP (from year 1989 to 2013), PubMed ( from year 1966 to 2013), and Cochrane Library (Issue,5,2013).Data were extracted and evaluated by two reviewers independently according to Cochrane Reviewers ’ Hand-book. The Cochrane Collaboration ’ s Revman 5.2.5 software was used for meta-analyses when necessary.
ResultsTwo trials involving 115 cases were included in the review .The results of meta-analyses showed that there was no significant difference of short-term curative rate for frozen shoulder between blockage and acupotomology (P>0.05).And the long-term effect rate [OR=0.09,95%CI (0.01, 0.93),P=0.04] and long-term total curative rate [OR=0.07,95%CI(0.02,0.26),P<0.0001] of acupotomology was superior to blockage in the treatment of frozen shoulder.
Conclusion Acupotomology may be superior to blockage in the treatment for frozen shoulder. However, due to low quality of the included studies , rigorously designed RCTs are needed to confirm the conclusion. Wu 2013

Wu Xiang, Jin Dezhong, Liu Fushui, Xu Hua. [Meta-analysis of acupotomy on frozen shoulder]. Traditional Chinese Medicine Journal (中医药通报). 2013;12(6):55-8. [170551].

ObjectiveTo evaluate the efficacy of needle-knife in the treatment of periarthritis of the shoulder with a meta-analysis.
Methods The computer searched Chinese biomedical literature database CBM (1978-2013), CNKI (1979-2013), VIP database (1989-2013), PubMed (1966-2013), EMBASE (1980-2013) 2013) and Cochrane Clinical Controlled Trials Center Register (2013 Issue 6), supplemented by manual search, were included in randomized controlled trials in which the treatment group was treated with a needle-knife therapy and the control group was treated with a non-needle-knife therapy. Two reviewers independently selected trials, extracted data, and cross-checked them for quality assessment with Cochrane System Reviewer's Manual 4.2.8. Meta-analysis was performed using RevMan 5.1 software.
ResultsA total of 6 randomized controlled trials of acupuncture for periarthritis of shoulders met the inclusion criteria, including 487 patients, and only 1 high-quality literature. Meta-analysis results showed that the total effective rate and cure rate of acupuncture for periarthritis of the shoulder were better than those of the control group. The total effective rate was OR = 6.31, 95% CI (2.83, 14.06), Z = 4.51, P <0.01; The cure rate was OR = 4.96, 95% CI (3.12,7.87), Z = 6.78, P <0.01.
Conclusion Needle-knife treatment of periarthritis of the shoulder is more effective. Needle-knife treatment of periarthritis of the shoulder may have certain advantages over other therapies. However, due to the limited number of included trials and the low quality of the literature, a large sample of high-quality randomized controlled trials is needed to further verify. Liu 2012 ★

Liu Fu-Shui, Jin Xiao-Fe, Guo Chang-Qing. [Systematic review of acupuncture versus acupotomology for frozen shoulder]. China Journal of Traditional Chinese Medicine and Pharmacy. 2012;3:582-585. [186924].

ObjectiveTo evaluate the clinical efficacy and safety of acupuncture versus acupotomology for frozen shoulder.
MethodsRandomized controlled trials (RCTs) of acupuncture versus acupotomology in the treatment of frozen shoulder were retrieved from CBM (1978 to 2010), CNKI (1979 to 2010), VIP (1989 to 2010), PubMed (1966 to 2010), and Cochrane Library (Issue 4, 2010). And some relevant journals were manually searched. Data were extracted and evaluated by two reviewers independently according to Cochrane Reviewers’ Handbook. The Cochrane Collaboration’s RevMan5. 1 software was used for meta-analyses.
Results6 trials involving 570 cases were included. The results of meta-analyses showed the total effect rate of acupotomology for frozen shoulder is higher than acupuncture, OR=7. 70, 95%CI [2. 58, 22. 99], Z=3. 66, P<0. 01. And the cure rate of acupotomology for frozen shoulder is higher than acupuncture, OR=5. 39, 95%CI [3. 48, 8. 32], Z=7. 58, P<0. 01.
ConclusionAcupotomology is superior to acupuncture in the treatment of frozen shoulder. However, due to low quality of included studies, rigorously designed RCTs are needed to confirm the conclusions.

1.2.3. Tiaokou Acupoint (ST38) Yang 2018 ☆

Yang C, Lv T, Yu T, Wong S, Lu M, Li Y. Acupuncture at Tiaokou (ST38) for Shoulder Adhesive Capsulitis: What Strengths Does It Have? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2018. [165357].

Objective Tiaokou (ST38) is used as a crucial distal acupoint for treating shoulder adhesive capsulitis (SAC) in traditional Chinese medicine. The objective of this study was to assess the effectiveness and safety of acupuncture at Tiaokou for treating SAC.
MethodsWe searched eight electronic databases without language restrictions. All the literature was processed to identify RCTs comparing acupuncture at Tiaokou with other therapies (e.g., acupuncture at local shoulder acupoints and nonsteroidal anti-inflammatory drugs). Two reviewers extracted trials and collected outcome data independently. A meta-analysis was performed following a strict methodology.
Results19 RCTs involving 1944 participants met our inclusion criteria. The majority of the trials were determined to be of low quality. Positive results were found for acupuncture treatment at Tiaokou (as sole treatment or in combination with shoulder acupoints), which resulted in an improved percentage of clinical effectiveness and Constant-Murley Score values, as well as a reduction in Visual Analogue Scale values of SAC patients.
Conclusion Our review found encouraging evidence for the effectiveness of acupuncture at Tiaokou for SAC. Nonetheless, despite stringent methodological analyses, these results need to be strengthened by additional RCTs of higher quality.

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. National Institute for Health and Clinical Excellence (NICE, UK) 2017 ⊕

CKS Clinical knowledge summaries). Shoulder pain. London (UK): National Institute for Health and Clinical Excellence (NICE). 2017:25P. [193257].

Frozen shoulder: Consider referral for physiotherapy. Acupuncture may be performed by the physiotherapist.

2.2. American College of Occupational and Environmental Medicine (ACOEM, USA) 2016 ⊕

Shoulder Disorders Guideline. American College of Occupational and Environmental Medicine. 2016. 379P. [181260].

Recommendation: Acupuncture for Treatment of Adhesive Capsulitis in Select Patients. Acupuncture is recommended for treatment of adhesive capsulitis in select patients. Indications - Adhesive capsulitis, especially moderate to severely affected patients with pain and loss of motion who do not respond sufficiently to NSAIDs, injection(s), and hydrodilatation; (Quraishi 07; Loew 05) recommended to be accompanied by an active exercise program. (Lathia 09; Sun 01) Frequency- Regimens vary widely in quality trials. An initial trial of 4 appointments would appear reasonable combined with a conditioning program of aerobic and strengthening exercises. An additional 4 appointments should be tied to improvements in objective measures after first 4 treatments, for a total of 8 appointments. (Guerra de Hoyos 04) Indications for Discontinuation - Recovery, plateau in recovery, noncompliance with exercise program, intolerance. Strength of Evidence - Recommended, Evidence (C) .