Treatment of Frozen Shoulder or Adhesive Capsulitis

Having been in the medical field since 1999, I’ve seen a lot of chronic pain.  Pain interferes with activities of daily living and makes it harder to deal with everyday stress.  Frozen shoulder is a particularly common pain problem that we can treat at Miami Beach Comprehensive Wellness Center.  Frozen shoulder is the layman’s term for “Adhesive Capsulitis.”  Adhesive Capsulitis occurs when excessive scar tissue forms in the glenohumeral joint of the shoulder, leading to a limited range of motion.  When it develops, a client might have the inability to lift their arm, interfering with tasks such as brushing their hair, reaching up to a high shelf or holding a beloved child or pet.  Often other accessory muscles are recruited to attempt to move the arm, resulting in imbalanced movements.  You can have primary adhesive capsulitis, which occurs as an inflammatory reaction.  Or it can be a secondary adhesive capsulitis, which occurs after a trauma, such as a fall, car accident or due to overuse while playing sports.

Frozen shoulder is correlated as having a higher occurrence in certain populations. [i]  Risk factors for Frozen Shoulder include:

• HLA B27 genetics, which is associated with a variety of autoimmune diseases
• Diabetes (both type I and type II)
• Thyroid disease
• Cerebrovascular disease
• Coronary artery disease
• Dupuytren’s disease
• Peyronie’s disease

Conventional medicine non-surgical treatments for Frozen Shoulder usually consists of physical therapy and corticosteroid or other medication injections.  In severe cases with extremely limited mobility for long periods of time, surgery is also an option.  The surgeon can break up the adhesive tissue and manipulate the shoulder while the patient is anesthetized.  However, in most cases, surgery is unnecessary.  Surgery is a last resort for cases which have not responded to non-surgical management.  

At Miami Beach Comprehensive Wellness Center, we have a lot of alternative options for non-surgical treatment of Frozen Shoulder.  

First, we like to do a systemic analysis of what is actually going on, with a good history and physical examination.  We ask questions such as, “Do you have a pre-disposing factor which is not well controlled, that might be contributing to chronic inflammation?”  For example, if you have autoimmune thyroid disease with high titers of thyroid antibodies, it can contribute to chronic inflammation, making it harder to heal a frozen shoulder.  If diabetes is not well controlled, frozen shoulder will not respond as well to physical therapy.  Determining what the most appropriate plan of care begins with a thorough evaluation.  We also evaluate the area surrounding the injury to look at body mechanics, such as muscle spasms, posture and gait.  

At MBCWC, we find that the most successful approach is to combine a variety of methods of treatment, including but not limited to:

• Addressing chronic inflammatory processes contributing to frozen shoulder
• Eating a low inflammation diet (the definition of this varies from one individual to another)
• Repletion of nutrient deficiencies
• Alignment of muscular imbalances with referrals to musculoskeletal structural specialists
• Acupuncture with moxibustion
• Cupping
• Homeopathic joint injections
• PRP injections
• Topical Verapamil

I will highlight and further discuss the following frozen shoulder treatments offered at MBCWC: acupuncture and moxibustion, cupping, homeopathic joint injections, and topical verapamil.  

Acupuncture and Moxibustion: Acupuncture with moxibustion has been shown in multiple scientific studies to be effective in treatment of frozen shoulder. [ii][iii] It can relieve pain and increase the mobility of the shoulder.[iv]  Frequently, after I treat a client with frozen shoulder, mobility is increased at the end of the first treatment session.[v]  Usually, on average, it takes a series of acupuncture treatments, about once a week for 2 months, to fully resolve frozen shoulder.  However, each individual is unique and responds on their own timeline.  Some complicated cases, might take longer.  While other cases might resolve much more quickly.  

Cupping: Cupping is a traditional component of Chinese medicine.  It is involves placing a vacuumed glass cup on an area of pain.  The vacuum lifts and separates the various layers of tissue within the body, enabling the breaking up of fibrotic scar tissue.  A bruise can occur, but does not always, at the site of cupping, when capillaries burst in response to the vacuum.  Usually the bruise from cupping is painless and resolves within 3-7 days.  Blood invigorates the injured area, triggering a cytokine chemical healing response to the injured area.  Cupping has been around for over 2,000 years in history and has been used to treat a broad range of medical conditions.  Cupping has multiple therapeutic effects, including pain reduction, immunomodulatory effects, hematological adjustments, anti-inflammatory effects and improvement of blood circulation.[vi]  

Homeopathic trigger point injections: Trigger points, often called “knots in muscles,” are discrete, focal, hyperirritable spots located in a taut band of spastic skeletal muscle.  Trigger points are often tender to palpation.  Injection of trigger points can help to alleviate muscle spasms which don’t respond to massage, stretching or muscle-relaxer medications.  In conventional medicine, doctors (most often pain management specialists) will inject trigger points with corticosteroids, botulinum toxin or anti-inflammatory medications.[vii]  Sometimes clients do not want these particular medications, because of side effects.  For example, common side effects of corticosteroids are elevated blood glucose levels and sugar cravings (making diabetes worse), weight gain, muscle wasting, irritability and insomnia.  Some people are very sensitive to medication side effects and might choose another option.  At MBCWC, we use homeopathic injections of Zeel or Traumeel into the trigger points.  Zeel is a homeopathic solution which contains only natural botanical and mineral extracts, including arnica, belladonna, comfrey root and echinacea.  It is used for treating pain, stiffness and inflammation of the joints.  It is an alternative to non-steroidal anti-inflammatories.  Traumeel is a homeopathic combination remedy, which is an anti-inflammatory, an anti-edematous and an anti-exudative combination of 12 botanical substances and 1 mineral substance, including arnica, calendula, chamomile and witch hazel. As these injections are homeopathic energetic medicines, there are no side effects and it can be safely combined with any other medications, therapies and treatments.  The only contraindication is a hypersensitivity to any ingredients.  We can easily add on a trigger point injection with homeopathic compounds, such as Zeel or Traumeel, to a functional medicine consultation or acupuncture visit.  

Topical Verapamil: Verapamil is an long-established anti-hypertensive medication, which works by blocking calcium channels.  The blockage of calcium channels relaxes the heart muscle and the smooth muscles of the blood vessel walls, decreasing blood pressure and restoring irregular heart rates.  Topical preparations of verapamil are made by a special compounding pharmacy and are used off-label (meaning not FDA-approved) to treat frozen shoulder, Dupuytren’s contracture and Peyronie’s disease.  All these conditions are associated with adhesion of the connective tissues.  The dose of verapamil is much smaller when applied topically, than taking a pill.  Theoretically, it helps to decrease the overgrowth of the collagen that forms scar tissue, by blocking calcium channels in the fibroblasts.[viii]  Several of our clients have responded well to topical verapamil, with minimal side effects, after failing conventional treatments for frozen shoulder.  

If you are experiencing frozen shoulder, please call our office to set up either a functional medicine consultation or an acupuncture visit.  We are happy to help you with any of the above methods and help you to find your own path to healing.

REFERENCES

[1] [1] Hai V. Le,¹ Stella J. Lee,¹ Ara Nazarian,² and  Edward K. Rodriguez^1,2Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments Shoulder Elbow. 2017 Apr; 9(2): 75–84.

Published online 2016 Nov 7. doi: 10.1177/1758573216676786 PMCID: PMC5384535 PMID: 28405218

[1] https://www.hkmj.org/system/files/hkm0112p381.pdf

[1] Ling Gao ¹, Xiao Li ², Dong-Bin Wang ², Mei-Lu Du ², Jin Xie ², Xi-Yan Gao ² [Clinical trial of treatment of frozen shoulder by intensive moxibustion plus acupuncture] PMID: 31056885 DOI: 10.13702/j.1000-0607.170817

[1] Mahsa Asheghan ¹, Amidoddin Khatibi Aghda ², Ebrahim Hashemi ¹, Mohammadtaghi Hollisaz ¹INVESTIGATION OF THE EFFECTIVENESS OF ACUPUNCTURE IN THE TREATMENT OF FROZEN SHOULDER PMID: 27698596 PMCID: PMC5034968 DOI: 10.5455/msm.2016.28.253-257

[1] Sven Schröder ¹, Gesa Meyer-Hamme ¹, Thomas Friedemann ¹, Sebastian Kirch ¹, Michael Hauck ^2 3, Rosemarie Plaetke ⁴, Sunja Friedrichs ¹, Amit Gulati ⁴, Daniel Briem ⁵Immediate Pain Relief in Adhesive Capsulitis by Acupuncture-A Randomized Controlled Double-Blinded Study PMID: 28371868 DOI: 10.1093/pm/pnx052

[1] Abdullah M.N. Al-Bedah,^a Ibrahim S. Elsubai,^a,∗ Naseem Akhtar Qureshi,^a Tamer Shaban Aboushanab,^aGazzaffi I.M. Ali,^a Ahmed Tawfik El-Olemy,^a,b Asim A.H. Khalil,^a Mohamed K.M. Khalil,^a and  Meshari Saleh Alqaed^aThe medical perspective of cupping therapy: Effects and mechanisms of action J Tradit Complement Med. 2019 Apr; 9(2): 90–97.  Published online 2018 Apr 30. doi: 10.1016/j.jtcme.2018.03.003 PMCID: PMC6435947 PMID: 30963043

[1] DAVID J. ALVAREZ, D.O., AND PAMELA G. ROCKWELL, D.O. Trigger Points: Diagnosis and ManagementAm Fam Physician. 2002;65(4):653-661 https://www.aafp.org/dam/brand/aafp/pubs/afp/issues/2002/0215/p653.pdf

[1] https://pdlabs.net/dupuytrens/whatisTvGel_dupuytrens.html