Shoulder adhesive capsulitis is reported to affect 2% to 5% of the general population. The
clinical course of adhesive capsulitis has been described in the literature ranging from
18-24 months, with persistent symptoms often lasting longer after range of motion has
returned. Fifty percent of individuals will report having mild pain or stiffness at 7-year
follow up. Treatment for adhesive capsulitis can be extensive with the average duration of
treatment being 4.7 months. In general, adhesive capsulitis is often thought of as a self
limiting diagnosis that significantly impacts a patients function and livelihood. Physical
therapists often prescribe exercise for the management of adhesive capsulitis including
stretching and strengthening. There is some support for exercise to provide moderate
improvements in function, mobility, and decreased pain but impairments including pain and
range of motion deficits persist even with exercise treatments.
Trigger point dry needling is a treatment approach often used by physical therapists that has
been purported to be effective for reducing pain and improving range of motion along with
improving function. Improvements in range of motion are associated with improvements in
function for patients with adhesive capsulitis. While dry needling does not directly treat
the tissues thought to be the primary factor in limiting range of motion, it does treat the
surrounding tissues, including trigger points, that have been associated with painful
shoulders including adhesive capsulitis. However, the direct investigation of dry needling
for shoulder adhesive capsulitis has been minimally investigated. While published papers on
dry needling for adhesive capsulitis exists, they are primarily case reports or case series.
The growth in utilization of dry needling as a treatment option with minimal evidence creates
a dilemma in practice.
This will be a single blinded randomized controlled trial comparing dry needling with
exercise versus sham dry needling and exercise for subjects with shoulder pain consistent
with adhesive capsulitis.
Patients undergoing physical therapy examination for adhesive capsulitis will be considered
for participation in the study. If the evaluating/treating physical therapist deems that the
patient may be appropriate for the study, he/she will approach the patient to gauge interest
in participating in the study. If the patient expresses interest, he or she will be referred
to a member of the study personnel (dry needling physical therapist) who will screen for the
inclusion and exclusion criteria. The study personnel will provide additional details
regarding the study requirements. The consent process may be initiated at this time or
deferred to a later time if the patient requests additional time to consider participation.
After consenting, the patient will be randomly assigned to one of the two treatment groups. A
digital coin flip (Siri) will be used for randomization procedures to determine the group
allocation (dry needling and exercise or sham dry needling and exercise). Exercise
prescription will be prescribed pragmatically. These will be based on the individual patient
examination and re-examination findings by the treating physical therapists, and supported by
best evidence. These exercises will address strength, flexibility and postural impairments
based on the clinical examination. The treating physical therapist will be blinded to the dry
needling treatment group assigned. The study personnel physical therapist will be blinded to
the outcomes.
For subjects that are randomized to the group receiving trigger point dry needling, active
and latent trigger points as described in previous protocols for dry needling of the shoulder
will be used to determine the appropriate muscles to treat. The study personnel physical
therapist will perform the dry needling (dry needling physical therapists). All dry needling
physical therapists have had considerable and appropriate training in trigger point dry
needling. Clean needle techniques will be applied including use of gloves by the physical
therapist and chlorhexidine wipes (or alcohol wipes if a chlorhexidine allergy is known) for
skin preparation. The dry needling procedure will involve using a sterile packaged Seirin ®
30-60 mm .25-.36 J-type monofilament needle. Palpation of the active or latent trigger point
will direct the study personnel as to where to treat. The needle will be inserted using an
insertion tube. Pistoning and twisting of the needle will be performed to elicit a local
twitch response. The study personnel will document the muscle treated, if a local twitch
response occurred, and if it was an active or latent trigger point. The frequency of dry
needling sessions will be determined in part by the dry needling physical therapist as well
as the subject. Subjects who defer subsuquent dry needling treatments will be noted
accordingly in the database.
For subjects that are randomized to the group receiving sham dry needling group, the
assessment procedure will be the same as the dry needling group. The same clean approach to
needling will be performed in order to mimic the procedure of actual trigger point dry
needling. Palpation of the active or latent trigger point will direct where to treat. The dry
needling physical therapists will be trained by the principal investigator on the sham dry
needling technique. A finishing nail cleaned with sterile alcohol swab will be inserted into
a tube with the tip of the nail extended out the end of the tube. The physical therapist will
use this sham needle over the area of the trigger point without skin penetration.
The finishing nail provides a minimal sharp sensation that is sometimes felt by patients
receiving dry needling. It also matches the potential perception that a patient has regarding
receiving any needle treatments. The force of the sham (finishing nail) treatment will be
just enough to produce a slight sharp sensation. The tap provided is just enough so that the
patient perceives a light sharp sensation. The procedure is set up similarly to actual dry
needling in that the physical therapist uses the same finger and holding position of the
tube. After the tap of the finishing nail, pseudo pistoning of the tube only (not the nail)
will be performed to match the duration of treatment time of actual dry needling. This will
range from 2 to 10 pistons varied per patient per muscle to match the approach of actual
trigger point dry needling. Furthermore, the finishing nail will be held toward the base of
the tube with firm pressure of the tube on the patient's skin to ensure consistent pressure
is provided.
For both groups, the patient will be prone so that the patient remains blinded to the
treatment. All set up procedures will take place after the patient has assumed the prone
positon. After the patient has assumed the prone position, the treating physical therapist
will prepare the treatment area as previously described. All materials associated with the
intervention will be discarded and removed from the treatment area before the patient comes
out of the prone position.
The duration of the total treatment program will be determined by the treating physical
therapist based on the impairments and re-evaluation of the subjects status. Outcome measures
will be collected at baseline. After one-month, or if the treating physical therapist deems
the subject is appropriate for discharge (whichever comes first), all outcome measures will
be reassessed. If the subject should need additional physical therapy after the one-month
period, the physical therapist will document the types of interventions provided, and any
additional healthcare utilization variables, including physical therapy utilization, and a
final collection of outcomes. Follow up will be conducted at one-week, one-month (or
discharge, whichever comes first) months and at 6 months to collect outcomes data.
