Frozen shoulder, otherwise known as adhesive capsulitis, is one of those tricky conditions which I have found respond well to treatment, but patience is required. I am a physiotherapist who likes to see quick results, either objectively or subjectively, ideally both!

However as we all know, the pathophysiology of the frozen shoulder often does not lend itself to such expectations and at the outset and it is important to make the patient aware of this fact.

That said, if the correct treatment approach is applied in the correct manner at the correct stage, the speed at a which a frozen shoulder may resolve (compared to no treatment or ‘wait and see’) can be increased significantly.

Conventional wisdom and anecdotal evidence would suggest a frozen shoulder left alone may burn itself out and resolve spontaneously in 12-24 months. With an integrated physiotherapy approach, in most cases my clients have returned to full pain free function after 3-4 months of treatment, weekly at first and then staggered sessions after about 4-6 sessions.

The placebo response is a psychobiological phenomenon we should use to good effect.

Like it or not, everything we do as physiotherapists has a placebo effect or exerts what may be referred to as ‘non specific effects’.

Whether it is manual therapy, exercise, electrotherapy or dry needling there always has been and always will be a portion of the therapeutic effect which is not necessarily specifically related to the technique itself and which relies on context, expectation, the quality of the therapeutic relationship and so on.

As dry needlers, the implication is usually that we are targeting muscle tissue, more specifically trigger points within taut bands of muscle. Typical dry needling involves an axial lift and thrust type technique where the needle is near fully withdrawn and reinserted at and angle of about 20-30 degrees off the vertical in different directions. The aim with this more vigourous approach is to locate the trigger point and elicit a local twitch response, thought to be key to the therapeutic effect of needling. Rotating the needle while within the muscular taut band or trigger point is also taught on dry needling courses as a method of direct, local stretching.

There are other ways to approach needling trigger points which may be more superficial but usually still penetrating the muscle tissue. Baldry (2005)  would describe 'leaving the needle in situ for some time but also intermittently twirling it' as a way of progressing treatment should short duration, superficial needling with no added stimulation be insufficient to elicit the desired clinical effects.

This technique of twirling or rotating either in a uni-or bidirectional manner is also commonly used as a method of providing added stimulation in more traditional approaches to Acupuncture.

First up, lets consider the function of the psoas major muscle. As well as being a primary hip flexor, it may also assist with lumbar extension in someone with a normal lordosis by forward tilting the pelvis. It assists flexion of the spine when bending as well as some external rotation of the hip. This has some bearing on how best to stretch the psoas which should not only include extension but also some internal rotation. This muscle has also been considered a stabiliser of the spine and hip joint and contributes to upright posture in sitting and standing.

As a pain referral source we often think of the psoas major referring to the anterior thigh and groin, but must remember that pain may also be projected in a vertical direction in a ‘gutter’ along either side of the lower lumbar spine as well as to the sacroiliac region and buttock (Travell & Simons, 1999) 

Image courtesy of Primal Pictures Anatomy for Acupuncture

This is part 3 in a series of blog posts where I am sharing key highlights I took away from presentations, by Professor Cesar Fernandez de Las Penas, at the recent annual Spring Conference of the BMAS.

Be sure to read the previous articles in this series:

• Part 1
• Part 2

From a clinical point of view it was noted the successive daily application of dry needling could result in excessive muscle damage based on rat studies and should be avoided. If a MTrP recurs after one session of needling where a local twitch response has been successfully elicited this would imply the cause has not been addressed. In this case treatment should be repeated making sure any perpetuating factors are addressed.

Professor de Las Penas then ran through some of the more recent research findings telling us that dry needling for myofascial shoulder pain is more effective than usual care and that dry needling MTrP of the pelvic floor muscles is one of the more clinically effective techniques for chronic prostatitis. Dry needling has also been shown to be efficacious for neck pain of myofascial origin with grade A1 evidence now available. In terms of which patients are likely to respond to dry needling, there is evidence to suggest that higher levels of pain along with sleep and psychological disorders are negative prognostic factors.