Shoulder Regional Interdependence: Original research
This is my capstone project from my manual therapy fellowship. It has a small sample size, therefore I did not attempt to submit it for publication. However, I believe there is a lot of useful information (yes, I'm biased! It did consume many many hours of my life) that I wish to share with you all. I hope you enjoy it and find it helpful in evaluating and treating your patients that present with primary complaints of shoulder pain. Okay, enough from me, enjoy........
Electric dry needling, cervicothoracic junction and 2nd rib manipulation improves short term outcomes in patients with shoulder pain: a retrospective comparison
Background: Shoulder pain is the third leading cause of orthopedic primary care visits. There is evidence to support dry needling and/or acupuncture for treating shoulder pain, as well as a regional interdependence model utilizing manipulation of the cervical spine, cervocothoracic junction and upper ribs.
Objective: To compare the addition of spinal and rib HVLAT manipulation and dry needling to standard physical therapy management of patients with the primary complaint of shoulder pain.
Study Design: Retrospective comparison
Methods: Patients charts with the primary complaint of shoulder pain from the past year was reviewed in order to create 2 comparison groups: standard physical therapy plus spinal manipulation and electric dry needling to the lower cervical, cervicothoracic junction and upper ribs and standard physical therapy. 4 patients met the inclusion/exclusion criteria, with a complete data set to analyze. To create homogeneity, patients treated with standard physical therapy where matches as close as possible.
Results: The percent improvements showed both clinically and statistically significant differences at 30 day on QuickDASH and NPRS scores. The percentage improvement on the QuickDASH and NPRS were 75.2% and 75.7% for the DN HVLAT group and 30.8% and 33.2% for the standard PT groups respectively.
Limitations: the small sample size allowed for significant differences between groups and the retrospective design did not randomize patients or have a standard screening and evaluation process for inclusion allowing for some variations within and between groups.
Conclusion: The addition of a regional interdependence model that utilizes HVLAT manipulation with electric dry needling to the lower cervical, cervicothoracic junction and upper ribs appears to have significant effects on pain and disability of patients with primary complaint of shoulder pain.
Shoulder pain is the third leading orthopedic condition seen in the outpatient primary care setting, behind neck and low back pain.(1) Meisen reported that in the year 2000 in the United States shoulder pain and dysfunction was directly responsible for $7 billion in medical expenses. (2) This is likely a result of what Bot et al. found, as they reported that less than 25% of patients with a new onset of shoulder pain reported recovery at 3 months, and only 32% at 1 year.3 Establishing a definitive diagnosis poses a challenge to the primary care provider, as shoulder pain can be a result of: bursitis, tendinitis, rotator cuff tear, adhesive capsulitis, impingement syndrome, thoracic outlet syndrome, cervical radiculopathy, avascular necrosis, glenohumeral osteoarthritis (OA), and other causes of degenerative joint disease or from traumatic injury, either in combination or as a separate entity. Rotator cuff disorders, adhesive capsulitis, and glenohumeral OA are all common causes of persistent shoulder pain, accounting for about 10%, 6%, and 2% to 5%, respectively, of all shoulder pain. (1,2,4-6) As a result of the shoulders complexity in structure and function there is a multiplicity of underlying conditions and structures that may be responsible for the resultant shoulder pain.(2,4,7,8) It has been demonstrated that both peripheral and central sensitization mechanisms are present in patients with shoulder pain and impingement syndrome.(9-13) Perhaps the answer to better outcomes lies within the question, “What is contributing to and or causing the shoulder pain?”
There has been a growing body of literature, going back to 2007 with Wainner at al’s article supporting the concept of a regional interdependence model for evaluation and treatment.(14-16) According to Wainner when it comes to musculoskeletal problems, “regional interdependence refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint”. Several studies have demonstrated improvements in shoulder pain and function of the shoulder following HVLAT manipulation to the thoracic spine, and ribs. (14,15,17,18) there is also substantial literature to support the use of dry needling or acupuncture for the treatment of shoulder pain, muscle tension and trigger points. (5,6,19-28) More importantly there is substantial evidence to support the mechanisms of electric dry needling or electric acupuncture to reverse the effects of peripheral and central sensitization in many different conditions.(29-34) Perhaps if we stop focusing primarily where the pain is and a specific tissue, and treat impairments all the way back to the spine, and spinal cord/cortical level we can improve on the lackluster 32% recovery from new onset shoulder pain at one year.
In the clinical setting it is common practice to use a multimodal approach to treatment, combining manual therapy, exercise and modalities. For research and scientific purposes most RCTs have very strict inclusion/exclusion criteria and follow a strict treatment protocol without variation within groups regardless of patient presentation. This may limit the potential benefits of a particular treatment to the patients within the study as well as ability for the clinician to generalize to their patient population. Thus the rational for a clinically based retrospective study, specific to each patient with commonality of primary complaint of shoulder pain and dysfunction and a semis-standardized approach to treatment utilizing HVLAT manipulation and electric dry needling within a regional interdependence model. The combination of HVLAT manipulation and electric dry needling was chosen because of the peripheral and central effects that both have been shown to have individually (6,14,15,17,20,21,23,29-43) There are different mechanisms underlying both, that when combined, theoretically should help to re-establish equilibrium across multiple systems involved in the patient experiencing shoulder pain and dysfunction.
Treatment notes of all shoulder patients for the past year were reviewed, and filtered by treatment received. Specifically for patients with shoulder pain who received HVLAT manipulation to the cervicothoracic junction, second or third ribs as well as dry needling to associated shoulder muscles and cervicothoracic region. Patients with positive ULTT, thoracic outlet tests, altered reflexes, and sensation or positive cervical radiculopathy cluster, or a recent cortisone injection where excluded. To create homogeneity between groups, the same time frame of patients was reviewed for patients treated with standard physical therapy (exercise, manual therapy, modalities, education and HEP) where matched as close as possible for: age, gender, length of current symptoms, presentation as well as starting scores for the outcomes utilized. The following data was recorded for each of the patients: gender, age, pain level on 0-10 NPRS, length of symptoms (current length of acute flare up if acute on chronic), QuickDASH scores, and number of visits during the initial 30 day period.
Outcome measures: Assessment of shoulder function and pain where recorded at initial evaluation and at the end of 30 days utilizing the QuickDASH, and the NPRS, 0-10. The QuickDash’s psychometric properties have been validated for use in patients with shoulder pathology, and has been shown to be both sensitive to change and capable of showing improvement in function44-49 the MCID for the QuickDASH ranges from 8 percentage points to 15.9 percentage points (48,49) and the MCID for the NPRS for patients with shoulder pain has been reported at 1.1. (49)
All patients underwent a similar stretching and strengthening program utilizing tubing and or dumbbells for standard RTC strengthening, scapula stabilizer strengthening, postural strengthening and stretching, proprioceptive and dynamic stability exercises for the shoulder complex, manual stretching and mobilization of the GHJ, cervical and thoracic spine, soft tissue treatments to involved musculature and modalities prn, including electric stimulation moist heat and ice packs. All HVLAT manipulations and dry needling treatments where performed by the same treating physical therapist with 8+ years of experience who holds a certification in spinal manipulative therapy and dry needling, a Diploma in Osteopractic and is currently a fellow in training through the American Academy of Manipulative Therapy. There is some variation within each of the two group’s exact treatments; however the distinguishing difference is the HVLAT manipulation and electric dry needling. The specific techniques and needling sites are described below.
All patients were screened for contraindication prior to dry needling. The treatment utilized a semi-standardized approach, with modifications based on patient’s presentation. All needles used where serin J-Type 0.30mm diameter with lengths varying from 30-60mm dependent on site and patient size. The semi-standardized treatment was performed in sidelying on the unaffected side with the arm resting over a pillow at the patient’s side. The set up targeted: 1. infraspinatus midway along the spine of the scapula 2 fingers breath inferior, 2. the supraspinatus at the lateral muscle belly in the supraspinatus fosa toward the spine of the scapula at the midpoint, 3. the musculotendinous junction of the supraspinatus just medial to the medial aspect of the AC joint, 4. Muscolotendinous junction of the infraspinatus just inferior to the posterior acromion down to the humeral head, 5. Teres major, 2 fingers breath superior to the posterior axilary crease, 6. Anterior deltoid and tenooseous junction medial to lesser tubercle and 7. Anterior deltoid middle muscle belly just medial to lesser tuberosity down to humeral head. The additional sites needled on some of the patients include the serratus posterior superior at rib levels 2 and 3 at 30* insertion angle from surface of the skin w/ a 40mm needle, rhomboids, levator scapula at medial border of scapula 30* from surface of the skin, Pec minor at corricoid, multifidi at C2, C5, C6 and T2. All needles were left in situ and prior to hooking up the electrical stimulation, all needles where wound uni-directionally until tissue grasp was noted. Electrical stimulation was set for 12-15 minutes at 2htz and 250 microseconds.
All patients were screened for contraindications prior to all manipulations. The segments targeted where depended on patient symptoms and therapist assessment of joint mobility using passive accessory motion testing in both supine and sitting for the cervical region and the upper thoracic and rib articulations in sitting, with the spine in neutral and in thoracic flexion as well as prone. If there was increased resistance to joint motion and or pain over a segment it was considered for manipulation.
All subjects received HVLAT manipulation to their CTJ in sitting, with a lateral break technique, and supine 2nd and or 3rd rib(s) at least once and some received additional upper thoracic and cervical segments targeted dependent on presentation. The most common cervical segments where C5/C6 which was manipulated in 3 of 4 and C1/C2 in 2 of 4.
The seated lateral break technique for the cervicothoracic junction was performed with the patient sitting on the treatment table with the target side arm resting over the therapist’s knee/thigh to allow the patient to relax and therapist to support and stabilize their torso. Three levers simultaneously where applied, the first is slight thoracic flexion by having the patient lean back against the therapist, with some upper thoracic lateral flexion by shifting then slightly toward the target side. The second, or long lever, was placed on anterior lateral forehead with your elbow behind their shoulder to create some extension, rotation toward and lateral flexion away, and third, or the short lever utilized the web space and medial aspect of MCP of index finger to gather up some of the upper trap horizontally toward C7/T1 all of these levers where simultaneously adjusted to manufacture a crisp joint end feel while in mid-range and a lateral and slightly anterior (20-30*) thrust with the short lever and slight extension lateral flexion with the long lever toward the short lever to gap open the CTJ on the side with the patients arm elevated.
The 2nd and 3rd rib technique was performed in supine with a towel roll across the sternum and the patients elbows lined up on the towel, with the far side arm on top. The therapist rolled the patient toward him positioned the volar aspect of his thenar eminence, just distal to the CMC joint with his thumb stacked over his 2nd carpal over the 2nd or 3rd rib just medial to the costrochondral angle, as the pat was rolled back to supine, a traction and slight supination of the underside arm was applied, with the forearm inside the scapula border, parallel with the spine. The patient was then side bent slightly toward the therapist and rolled roughly 30* past neutral, the longer lever was created with the therapists epigastric region over the patients elbows with a compressive force into the table over the underside hand and target rib with a quick controlled body drop.
The cervical techniques utilized a cradle hold with the short lever on the side you want to manipulate, the therapists thumb along the ramus of the jaw with the index finger over the posterior arch of the superior vertebrae of the target joint with the elbow in line with his body, and the long lever cradling the opposite side of the lateral and slightly posterior skull. A combination of rotation, side bending/ side shifting and slight extension upper, or flexion lower where simultaneously introduced. The combination is roughly 40-45* rotation, 10-15* side bend and 2-5* extension or flexion. As these levers are put on mini impulses to test the combination and fine tune where applied, once the barrier was achieved one last priming impulse was performed and then came slightly off the barrier 5-6* while maintaining all the levers with a thrust primarily into rotation of roughly 12*, or 6* into and past the manufactured barrier, with slight side bend and equal counter of the long lever to focus the forces to the target segment and facilitation rotation and side bending.
The upper thoracic was targeted similar to the rib technique in supine with a towel roll across the chest and arms crossed over with elbows lined up over the towel, and a loose fist grip with the inferior segment spinous process in the space between the thenar eminence and middle phalange, and the transverse processes over the thenar and middle phalange. As the patient was rolled to supine traction was applied to the thoracic segment, some side bend toward and then a thrust through the epigastric region through the folded arms was delivered into the table over the therapists underside arm.
IBM SPSS software version 22 for windows was utilized to run all statistical analysis. Independent samples t-tests with P = 0.05 were run to compare groups at initial and at 30 days for NPRS and QuickDASH scores using percentage change from initial to 30 days to adjust for differences in starting scores for both. It has also been the general cut point of a 50% improvement in disability and or NPRS to be indicative of a positive outcome in physical therapy research articles looking at impact of treatment.50-55
The individual data separated by group for age, gender, primary icd-9 or 10 diagnosis, duration of symptoms, percent improvement on QuickDASH and percent improvement of NPRS is shown in table 1.
The independent t-tests across groups for age, duration of symptoms, initial NPRS and initial QuickDASH proved homogeneity across groups for all except initial pain, the standard PT groups initial mean pain level was 8.25 compared to the DN HVLAT group at 6, there was no statistical difference across groups for the others, the specifics are listed in table 2.
In order to compare pain and QuickDASH across groups the percentage change from initial to 30days was calculated. At the 30 days NPRS showed a statistically significant difference between groups with p= .003 and QuickDASH at p=.017.
When percentage improvement are compared across groups it shows statistical significance for both, with NPRS p=.014 and QuickDASH p=.011 with the DN HVLAT group showing a 44.45% greater mean reduction in QuickDASH score and 42.50% greater mean reduction in NPRS at 30 days.
Limitations: Although the study is level III evidence being a retrospective comparison, it provides a more clinical approach that can be argued provides the clinician a viable option and clinical reasoning for treating a more heterogeneous group of patients presenting to the clinic with primary complaint of shoulder pain. In my opinion, a lot of study designs limit the idea of treating the person as a whole, and fully addressing all impairments with the goal of restoring equilibrium across all systems. The small sample size did allow for larger variances across groups and statistical significance during analysis, and may likely show less of a gap as more patients balance out the means across groups. However the differences both within the DN HVLAT group and across groups cannot be ignored or discredited, as the DN HVLAT group exceeded the MCID of the QuickDASH and NPRS.
To my knowledge no other study has looked at the combination of electric dry needling along with HVLAT manipulation into a regional interdependence model in the treatment of patients with primary complaint of shoulder pain. It has been shown that patients with unilateral shoulder impingement have significantly more trigger points in the levator scapula, supraspinatus, infraspinatus, subscapularis, pectoralis major and biceps brachii muscles as compared to controls 9 As de-la-Llave-Rincon et al.10 point out, “Any innervated structure in the cervical and thoracic spine can be a source of nociception and provide an input mechanism for the experience of upper quadrant pain.” Shah et al, Found higher concentrations in the active MTrPs of: Bradykinin (BKN), substance P (SP), calcitonin gene-related peptide (CGRP), tumor necrosis factor alpha, interleukin 1β (IL-1β), Serotonin (5-HT) and Norepinephrine (NE). Active MTrPs have an acidic millieu at and around them. The acidic environment results in changes in the properties of nociceptors and dorsal horn neurons which inhibit Acetolcholene esterase, which breaks down Ach, stimulates production of BKN ,substance P and CGRP are also released from dorsal horn and sustained and prolonged exposure in the spinal cord results in interneuron death, 56 which is the mechanism leading to central sensitization and referred pain. Kuan et al. used a staining process to follow the nerve circuit from a MTrP, by injecting an active MTrP in the biceps femoris muscle of 9 rats and found stained neurons in the ventral horn motor neurons, specifically Alpha and dorsal root ganglia at L3-L5 with highest concentration at L5. This shows that the MTrP is connected to sensory neurons in the dorsal root ganglia and the motor neurons in the ventral horn of the spinal cord.(57)
Instead of a tissue-based approach of treatment Fritz and Brennan have instead proposed a treatment-based-classification where greater emphasis is placed on matching the patient to optimal interventions based on the identification of signs and symptoms collected during the interview and physical examination.58 To this point, Hindalgo-Lozano et al. suggest that both peripheral and central sensitization mechanisms exist in patients with shoulder impingement syndrome9. The question then arises, what is the best way to treat the peripheral and central mechanisms to deliver the best results for our patients? The results of this study are a starting point to an answer to that question.
Wassinger et al. looked at the acute effects of lower cervical (C5-C7), cervicothoracic and thoracic manipulations on pressure pain threshold and self-reported pain in experimentally induced shoulder pain. They concluded “Physiotherapists may consider the combination of such techniques to achieve short-term hypoalgesic effects and facilitate the application of more active interventions.
Paterson (59) reports that scapula mechanics is highlighted as a main cause of dysfunction in the shoulder and are commonly assessed in patients with SIS, and that dysfunction of the scapula stabilizers has been highlighted clinically in subjects with SIS (59). As Mintken (38) questions, does the shoulder pain precede these impairments or perhaps are the impairments in this region a primary contributing factor to the development of shoulder pain?
A seemingly less focused on region when looking at scapulohumeral motion and mechanics are the ribs which the scapula happens to sit on top of and should slide and rotate smoothly over. The involvement of the second and third ribs in shoulder pain have been demonstrated first by Boyle with 2 case reports, (18) demonstrating that the addition of HVLAT manipulation to the 2nd rib articulation resulted in positive outcomes for both patients who had previously not been responding to other common RTC impingement based treatments. His anatomic explanation is that the 2nd rib narrows or compresses the 2nd thoracic dorsal ramus, which becomes cutaneous over the posterior shoulder and extends to the AC joint.18 Strunce et al. showed positive immediate effects on shoulder pain, shoulder ROM and patient-perceived GROC, further supporting the regional interdependence model of the thoracic spine, upper ribs and the shoulder. (14) Dunning et al. published a single arm study on 2nd and 3rd rib manipulation for patients presenting with primary complaint of shoulder pain with good improvements noted after 2 sessions, the first including a 2nd or 3rd rib HVLAT manipulation and the second a T2/T3 HVLAT manipulation(17). Sueki and Chaconas further support and break down the regional interdependence model involving the thoracic spine and shoulder with proposed mechanisms. They describe the 4 most commonly used rehabilitation paradigms of neurophysiological, biopsychosocial, biochemical and pathoanatomical and that when any of these become altered our bodies adjust in an attempt to restore homeostasis or equilibrium. The process of adaptation in order to restore homeostasis is our bodies allostatic response. It has been suggested that alterations in homeostasis are directly related to persistent pain. They propose that regional interdependence is really an example of an allostatic response.(15)
HVLAT spinal manipulation has been shown to have multiple proposed mechanisms underlying the reduction in pain and restoration of motion. The mechanical effects are increased elasticity of the joint capsule and improved ROM, the biochemical effect is the reduction of C-fiber secretion of substance-P, and the neurophysiological effects are thought to be a response of activating mechanoreceptors in the target region which modulates afferent nerve activity of the GTO and muscle spindle resulting in increased force output from associated muscles. The Hypoalgesic effects are regulated through the dorsal horn mediated inhibition of C-fiber input through the dPAG non-opioid descending pain inhibition by inhibiting substance-P.13-15,35,60-64 The downstream neurophysiological effects on segmental muscles underlies the rationale for the lower cervical and cervicothoracic junction manipulations knowing that C5/C6 segment provides motor innervation to the rotator cuff and some of the scapula stabilizers with most of the remaining scapula musculature being innervated from the cervicothoracic junction region. The manipulation is thought to be responsible for breaking the pain cycle and the associated myofascial trigger points in the associated muscles to the target segment.(15)
There is a growing amount of literature supporting dry needling, electric dry needling and acupuncture for the treatment of shoulder pain. (5,6,19,21-25,29-34,42,43,65,66) Ceccherielli found that deep manual acupuncture 25mm depth insertion into involved shoulder muscles resulted in increased reduction in pain and disability as compared to superficial manual 4mm of depth insertion.(20) Langevin has demonstrated in multiple studies the pain relieving and mechanincal effects of needle insertion and winding. The winding results in tissue displacement up to 4cm away, and in ATP release, which is broken down into adenosine which block nociceptive nerve endings.(26-28,67) Zhang et al. (29) have provided a vast area of mechanisms of acupuncture and electric acupuncture on pain reduction in inflammatory, neuropathic, cancer and visceral pain. In inflammatory pain elecroacupuncture inhibits both the sensory and the affective components of inflammatory pain. This is accomplished through peripheral, spinal and supraspinal mechanisms with the involvement of multiple bioactive molecules including opioids, N/OFQ, serotonin, norepinephrine, glutamate receptors and transporters, cytokines, and signal molecules. The opioids play a central role in the inhibition of all types of pain through desensitization of peripheral nociceptors, decrease proinflammatory cytokines in the periphery decreasing cytokines and substance-P in the spinal cord and also influence the affective component of pain. The opioids also activate the descending inhibitory system resulting in the release of serotonin and norepinephrine which aid in additional inhibition of pain. (29) This mechanism is an important piece of the puzzle for the body to return to an allostatic state after initial onset of shoulder pain and dysfunction.
The ability to treat shoulder pain and dysfunction from multiple aspects helps to create the ideal environment for recovery, or as Sueki and Chaconas, refer to it as allostasis. The interconnection and interaction of all the organ systems should be attempted to be restored to equilibrium as efficiently as possible. This can only be accomplished if we intentionally treat the neurologic, chemical, myofascial, vascular, segmental innervations, spinal cord and even cortical levels with optimal combinations of proven techniques.
Despite the small sample size, the DN HVLAT group showed both statistically significant and more importantly clinically relevant improvements when compared to the Standard PT group in both the QuickDASH and pain level as measured with the NPRS.
This article supports the utilization of a regional interdependence model that incorporates a multimodal treatment to address the spinal cord and cortical levels through HVLAT manipulation and electric dry needling to involved and associated cervical, thoracic and rib articulations, neural and connective tissues and muscle impairments that contribute to shoulder pain and dysfunction. Although a small sample, it is a starting point to the incorporation of electric dry needling and HVLAT manipulation into the regional interdependence model for the treatment of patients with the primary complaint of shoulder pain. This is grounds for future studies with larger sample sizes and sound methodology to further investigate the combination of electric dry needling and spinal and rib manipulation in the treatment of patients presenting with primary complaint of shoulder pain and disability.
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