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Effects of Dry Needling on Shoulder, Arm, and Hand Pain Post CVA

Case Study: Effects of Dry Needling on Chronic Shoulder, Arm, and Hand Pain Post CVA

JOSPT: A detailed description of the management of a unique clinical case, including relevant patient characteristics, examination, evaluation, diagnosis, and description of the interventions that were provided.

Title: Case Study: Effect of Dry Needling on Chronic Shoulder, Arm, and Hand Pain Post CVA

Key Words: Dry Needling, myofascial pain syndrome, physical therapy, manual therapy, CVA, shoulder pain, hemiparesis, chromic pain

Structured Abstract:

  • Introduction (1-2 sentences)
    • Chronic shoulder pain is a major complaint for many patients following a CVA (cite). Shoulder pain following CVA is typically due to weakness of the muscles holding the shoulder in its proper position and subsequent subluxation of the shoulder joint. Treatment for shoulder pain after CVA includes physical therapy, orthotic support, steroid injections, nerve blocks, and oral medication. Partial resolution of the shoulder pain occurs in many patients after several weeks to months. Dry needling (DN) has recently been discussed in the literature to address myofascial pain syndrome (MPS) or trigger points with a high degree of success. There are no articles discussing the use of dry needling or intramuscdular needling to address shoulder pain following CVA. This report will describe a single session of intramuscular dry needling to address chronic shoulder, arm, and hand pain following a CVA.
  • Case presentation
    • History:A 71 year old female presented to physical therapy for an evaluation and treatment for her left scapular, shoulder, arm, and hand pain that had begun following a CVA 9 years prior. The patient had a medical history of diabetes mellitis, HTN, and dyslipidemia all for which she was medically managed. The patient described her CVA as “waking one morning with altered sensation in her left arm”. The patients showered and went to work with her symptoms worsening and so she drover herself to the ER where she was diagnosed with dangerously high B/P, and a CVA was suspected. The patient was referred for a CT scan which revealed a sarcoid lesion in her intrathoracic and abdominal region, which was successfully treated with a trial of prednisone. The patient reported few impairments following her CVA with left shoulder weakness and pain as her primary concern. The patient was referred to PT and reported that she was instructed to perform Active range of motion (AROM) and resisted shoulder exercise which increased her pain and resulted in a bad experience. The patient did not return to therapy. The patient received additional treatments for her pain including steriod injection and several nerve ganglion blocks which helped her pain somewhat. The patient was diagnosed with frozen shoulder by her PT, although this was a questionable diagnosis during an informal physical therapy examination and was not confirmed or treated.
    • Primary Complaint: The patient reported primary pain in her left scapular and shoulder area with secondary radiating pain in her arm and hand, occurring each day for the past 9 years intermittently throughout the day. Patient reported that she had elimination of her pain while she was treating patients in her work as a psychiatrist. The patient rated her primary pain using the numerical pain rating scale (NPRS) and visual analog scale (VAS) as 5-6/10 and her secondary radiating pain as 3/10 during the examination.
    • Observation: Patient presented with rounded shoulders, sacral sitting and mild to moderate posterior thoracic and scapular muscle atrophy and mild to moderate adipose tissue noted. Patient presented with left hand Middle Interphalangeal (MIP) joint contractures with inability to flex the MIP joints and hyperextension at digits 2-5 in a swan neck like deformity. Patient commented that she used her hand like a “spade”for functional purposes. The patient had a deep red color in her left hand compared to normal color in her right.
    • Palpation: Patient reported tender to touch at the upper trapezius muscles and levator scapular muscles at the left shoulder region. The infraspinatus and supraspinatus muscles were also tender to touch and patient reported reproduction of her pain in her arm that increased to a 8-9/10 with specific compression. The UT muscles were firm to the touch at the superior and superficial level as well as deeper to the first rib.
    • ROM: Seated cervical spine rotation was measured using goniometry with the axis positioned above the patient at the peak of the head/ occiput, the stable arm dissecting the patients thorax and the moving arm lined up with the patients nose and tactile cues to prevent compensatory thoracic rotation: Right rotation limited to 50 degrees and left rotation 46 degrees without pain. Patient demonstrated full flexion although reported 1/10 pain in her left shoulder at end range. No pain with cervical extension and lateral flexion was not assessed. Shoulder flexion was measured in sitting with the axis of the goniometer positioned on the lateral arm over the GH joint, the stable arm along the lateral border of the scapula and the moving arm along the midline of the humerus. Right GH flexion limited to 150 deg pain free, and left shoulder flexion limited to 135 with minimal movements of the scapula noted.
  • Management
    • The patient transitioned to supine and was unable to lie without a standard medium pillow under her head. Palpation for the tender spots at the posterior neck, upper trapezius, SCMM, Levator scapulae, and scalenes  revealed tender points all along the upper trap on the left side in isolation and compared to the the asymtomatic right side. Patient reported pain at levels 8-9/10 with palpation and reproduction of chief complaint at primary location and secondary location. Once PT obtained the most painful location, the proximal UT muscle at the posterior triangle of the neck, the area where the shoulder meets the neck, and the distal attachment at the the acromion, the PT used a pincer grasp to hold the muscle away from the neck to isolate the muscle belly and a Serin No.8 (0.30) x 50mm accupuncture needle was inserted from an anterior to posterior  direction with the inferior to superior angle. Multiple twitching was visible and palpable with the patient reporting peaks in pain with each insertion of the trigger point. The patient returned to sitting without any improvement reported. The patient transitioned to prone and the same size needles were inserted from a posterior to anterior inferior to superior angle with multiple twitching palpable. A second needle was inserted at the insertion of the Levator (medial superior border of the scapulae) and no twitching could be felt and no pain was reported. Continued palpation in the area revealed no reports of pain from the patient at the upper portion of the upper trapezius as well as the lower portion except at the are above the lower portion of the  levator, yet above the insertion point. An needle was inserted at a perpendicular angle with the supervision of a physician to insure safety of the lungs and nerves and a deep twitch was palpable and reproduction of the patients pain was reported. The patient transitioned to sitting and reported no pain in her primary area although reported a “fire” and “burning sensation ” into her symptomatic arm. Patient sat with ice applied to her treated area x 7 minutes and reported complete resolution of pain at her primary and secondary locations. The patients symptomatic hand  appeared equal in color to her uninvolved hand as well. The patient remained pain free at day 7.
  • Discussion
    • Myofascial pain syndrome which is a highly occurring cause of pain throughout the world. Chronic shoulder pain is common in patients following CVA., and is thought to be due to  muscle weakness and subluxation. Common treatments for myofascial pain including chronic shoudler pain after due to CVA consist mostly of conservative management including hot packs, cold packs, oral OTC medications such as NSAIDS, ibuprofin, and muscle relaxors, and physical therapy. Physical therapy interventions largely consist of stretching, manual therapy, massage, and modalities including TENS, ultrasound, hot packs, cold packs, and more recently dry needling. The second phase of treatment includes steroid injections, nerve blocks, and opiod medications. Tertiary interventions include surgery such as decompression  or tendon repair.
    • Dry needling has been shown to be an effective intervention for myofascial pain syndrome although is continues to be an underutilzed intervention in the USA. This may be due to the lack of exposure, political restrictions, education, or all of the above. There are no studies reporting the use of dry needling for chronicl shoulder pain after CVA. This case report introduces a new use of dry needling in physical therapy and rehabilitation and higher quality studies should be performed to identify this low risk, highly effective intervention.

Introduction:

  • Literature review
    • Myofascial pain syndrome which is a highly occurring cause of pain throughout the world. Chronic shoulder pain is common in patients following CVA., and is thought to be due to  muscle weakness and subluxation. Common treatments for myofascial pain including chronic shoudler pain after due to CVA consist mostly of conservative management including hot packs, cold packs, oral OTC medications such as NSAIDS, ibuprofin, and muscle relaxors, and physical therapy. Physical therapy interventions largely consist of stretching, manual therapy, massage, and modalities including TENS, ultrasound, hot packs, cold packs, and more recently dry needling. The second phase of treatment includes steroid injections, nerve blocks, and opiod medications. Tertiary interventions include surgery such as decompression  or tendon repair.
    • Dry needling has been shown to be an effective intervention for myofascial pain syndrome although is continues to be an underutilzed intervention in the USA. This may be due to the lack of exposure, political restrictions, education, or all of the above. There are no studies reporting the use of dry needling for chronicl shoulder pain after CVA. This case report introduces a new use of dry needling in physical therapy and rehabilitation and higher quality studies should be performed to identify this low risk, highly effective intervention.
  • Gap in body
    • A Search in Pubmed for Dry Needling AND shoulder pain Post CVA resulted in 0 articles
    • A Search in Pubmed for Dry Needling AND shoulder pain resulted in 17 articles, none reporting on post CVA shouler pain.
    • A Search in Pubmed for Shoulder pain AND CVA resulted in 360 articles, none reporting on the use of dry needling for shoudler pain post CVA
  • Interesting components of current case
    • The patient is highly educated (MD), employed, and functional with common symptoms of shoulder pain following a stroke. The patient is in the chronic phase of post CVA, who has had conventional treatments for her pain without resolution. The patient responded unusually well to a single physical therapy treatment using an underutilized intervention, namely dry needling.
  • Purpose of report
    • There are no articles discussing the use of dry needling or intramuscdular needling to address shoulder pain following CVA. This report will describe a single session of intramuscular dry needling to address chronic shoulder, arm, and hand pain following a CVA. This case report introduces a new use of dry needling in physical therapy and rehabilitation and higher quality studies should be performed to identify this low risk, highly effective intervention.

Case description:

    • History:A 71 year old female presented to physical therapy for an evaluation and treatment for her left scapular, shoulder, arm, and hand pain that had begun following a CVA 9 years prior. The patient had a medical history of diabetes mellitis, HTN, and dyslipidemia all for which she was medically managed. The patient described her CVA as “waking one morning with altered sensation in her left arm”. The patients showered and went to work with her symptoms worsening and so she drover herself to the ER where she was diagnosed with dangerously high B/P, and a CVA was suspected. The patient was referred for a CT scan which revealed a sarcoid lesion in her intrathoracic and abdominal region, which was successfully treated with a trial of prednisone. The patient reported few impairments following her CVA with left shoudler weakness and pain as her primary concern. The patient was referred to PT and reported that she was instructed to perform AROM and resisted shoulder exercise which increased her pain and resulted in a bad experience. The patient did not return to therapy. The patient received additional treatments for her pain including steriod injection and several nerve ganglion blocks which helped her pain somewhat. The patient was diagnosed with frozen shoulder although this was a questionable diagnosis made by a physical therapist in an informal examination and was not confirmed or treated.
    • Primary Complaint: The patient reported primary pain in her left scapular and shoulder area with secondary radiating pain in her arm and hand, occurring each day for the past 9 years although not all day. Patient reported that she was not aware of her pain while she was treating patients in her work as a psychiatrist. The patient rated her primary pain using the NPRS and VAS as 5-6/10 and her secondary radiating pain as 3/10 during the examination.
    • Observation: Patient presented with rounded shoulders, sacral sitting and mild to moderate posterior thoracic and scapular muscle atrophy and adipose tissue noted. Patient presented with left hand Middle Interphalangeal joint contractures with inability to flex the MIP joints and hyperextension at digits 2-5 in a swan neck like deformity. Patient commented that she used her hand like a “spade”. The patient had a deep red color in her left hand compared to normal color in her right.
    • Palpation: Patient reported tender to touch upper trapezius muscles and levator scapular muscles at the left shoulder region. The infraspinatus and supraspinatus muscles were also tender to touch and patient reported reproduction of her pain in her arm that increased to a 8-9/10. The UT muscles were firm to the touch at the superior and superficial level and deeper to the first rib as well.
    • ROM: Seated cervical spine rotation was measured using goniometry with the axis positioned above the patient at the peak of the head/ occiput, the stable arm dissecting the patients thorax and the moving arm lined up with the patients nose and tactile cues to prevent compensatory thoracic rotation: Right rotation limited to 50 degrees and left rotation 46 degrees without pain. Patient demonstrated full flexion although reported 1/10 pain in her left shoulder at end range. No pain with cervical extension and lateral flexion was not assessed. Shoulder flexion was measured in sitting with the axis of the goniometer positioned on the lateral arm over the GH joint, the stable arm along the lateral border of the scapula and the moving arm along the midline of the humerus. Right GH flexion limited to 150 deg pain free, and left shoulder flexion limited to 135 with minimal movements of the scapula noted.
  • Differential diagnosis
    • myofascial pain syndrome was suspected although consideration of alternate causes was considered including fibromyalgia, CPRS, RSD, and nerve damage, spasticity, neurological causes
  • Raw data

Management and outcomes

  • Plan of care
    • The patient was visiting her son from out of state and was present for a single session f of examination, evaluation and treatment if applicable
  • Actual care provided
    • The patient transitioned to supine and was unable to lie without a standard medium pillow under her head. PT palpated for the tender spots at the posterior neck, upper trapeziu s, SCMM, Levator scapulae, and scalenes. Tender points were found all along the upper trap on the left in isolation and compred to the the asymtomatic right side. Patient reported pain at levels 8-9/10 with palpation and reproduction of chief complaint at primary location and secondary location. Once PT obtained the most painful location, the proximal UT muscle at the posterior triangle of the neck, the area where the shoulder meets the neck, and the distal attachment at the the acromion, the PT used a pincer grasp to hold the muscle away from the neck to isolate the muscle belly and a Serin No.8 (0.30) x 50mm accupuncture needle was inserted from an anterior to posterior  direction with the inferior to superior angle. Multiple twitching was visible and palpable with the patient reporting peaks in pain with each insertion of the trigger point. The patient returned to sitting without any improvement reported. The patient transitioned to prone and the same size needles were inserted from a posterior to anterior inferior to superior angle with multiple twitching palpable. A second needle was inserted at the insertion of the Levator (medial superior border of the scapulae) and no twitching could be felt and no pain was reported. Continued palpation in the area revealed no reports of pain from the patient at the upper portion of the upper trapezius as well as the lower portion except at the are above the lower portion of the  levator, yet above the insertion point. An needle was inserted at a perpendicular angle with the supervision of a physician to insure safety of the lungs and nerves and a deep twitch was palpable and reproduction of the patients pain was reported.
  • Frequency of visits
    • The patient was treated during the initial session
  • Attendance
    • The patient was present for one session
  • HEP compliance
    • not applicable
  • Outcomes
    • The patient transitioned to sitting and reported no pain in her primary area although reported a “fire” and “burning sensation ” into her symptomatic arm. Patient sat with ice applied to her treated area x 7 minutes and reported complete resolution of pain at her primary and secondary locations. The patients symptomatic hand  appeared equal in color to her uninvolved hand as well. The patient remained pain free at day 7.
  • Discharge information
    • The patient was instructed to use ice as needed no more than 12 minutes at t atime with instruction to place a thin sheet between the ice and her skin, to wait for numbness to occur and to stretch the UT several times a day

Discussion

  • Limitations
    • The limitations of this study include the inherent limitations of a case report, that is to say, it cannot be used to demonstrate any effectiveness, efficacy, or significance. Additionally, the details of the previous treatments are unavailable, nor the immediate results from the clinicians perspective. The patient and her husband, despite highly educated and of sound mind, are sure to have forgotten the details of treatments, some of which have occurred as long as 9 years prior. Finally, the patient may not reflect the usual patient with shoulder pain following stroke since she continues to work in a field that does not require constant use of he non-dominant hand.
  • Adds to body of knowledge
  • Relates to current research
  • Novelty points
  • Future studies

Conclusion

Acknowledgments

Patient consent

Tables

 

BellairePT

Bellaire Physical Therapy

Abraham Lieberman, PT, DPT

Doctor of Physical Therapy

5420 DASHWOOD, SUITE 306

Houston, Texas 77081

 

Abraham@BellairePT.com

www.BellairePT.com

Toll Free (855) 713- 7827

Fax: (713)-456-2583

 

The contents of this email or fax message and any attachments are intended solely for the addressee(s) named in this message.  This communication is intended to be and to remain confidential and may be legally privileged.  If you are not the intended recipient of this message, or if this message has been addressed to you in error, please immediately alert the sender of this fax and then destroy this message and its attachments.  Do not deliver, distribute or copy this message and / or any attachments if you are not the intended recipient, do not disclose the contents or take any action in reliance upon the information contained in this communication or any attachments.

 

On Thu, Dec 4, 2014 at 3:15 PM, Dr. Abraham Lieberman, PT, DPT <Abraham@bellairept.com> wrote:

JOSPT: A detailed description of the management of a unique clinical case, including relevant patient characteristics, examination, evaluation, diagnosis, and description of the interventions that were provided.

Title: Case Study: Effect of Dry Needling on Chronic Shoulder, Arm, and Hand Pain Post CVA

Key Words: Dry Needling, myofascial pain syndrome, physical therapy, manual therapy, CVA, shoulder pain, hemiparesis, chromic pain

Structured Abstract:

  • Introduction (1-2 sentences)
    • Chronic shoulder pain is a major complaint for many patients following a CVA (cite). Shoulder pain following CVA is typically due to weakness of the muscles holding the shoulder in its proper position, and subsequent subluxation of the shoulder joint. Treatment for shoulder pain after CVA includes physical therapy, orthotic support, steroid injections, nerve blocks, and oral medication. Partial resolution of the shoulder pain occurs in many patients after several weeks to months. Dry needling has recently been discussed in the literature to address myofascial pain syndrome or trigger points with a high degree of sucess. There are no articles discussing the use of dry needling or intramuscdular needling to address shoulder pain following CVA. This report will describe a single session of intramuscular dry needling to address chronic shoulder, arm, and hand pain following a CVA.
  • Case presentation
    • History:A 71 year old female presented to physical therapy for an evaluation and treatment for her left scapular, shoulder, arm, and hand pain that had begun following a CVA 9 years prior. The patient had a medical history of diabetes mellitis, HTN, and dyslipidemia all for which she was medically managed. The patient described her CVA as “waking one morning with altered sensation in her left arm”. The patients showered and went to work with her symptoms worsening and so she drover herself to the ER where she was diagnosed with dangerously high B/P, and a CVA was suspected. The patient was referred for a CT scan which revealed a sarcoid lesion in her intrathoracic and abdominal region, which was successfully treated with a trial of prednisone. The patient reported few impairments following her CVA with left shoudler weakness and pain as her primary concern. The patient was referred to PT and reported that she was instructed to perform AROM and resisted shoulder exercise which increased her pain and resulted in a bad experience. The patient did not return to therapy. The patient received additional treatments for her pain including steriod injection and several nerve ganglion blocks which helped her pain somewhat. The patient was diagnosed with frozen shoulder although this was a questionable diagnosis made by a physical therapist in an informal examination and was not confirmed or treated.
    • Primary Complaint: The patient reported primary pain in her left scapular and shoulder area with secondary radiating pain in her arm and hand, occurring each day for the past 9 years although not all day. Patient reported that she was not aware of her pain while she was treating patients in her work as a psychiatrist. The patient rated her primary pain using the NPRS and VAS as 5-6/10 and her secondary radiating pain as 3/10 during the examination.
    • Observation: Patient presented with rounded shoulders, sacral sitting and mild to moderate posterior thoracic and scapular muscle atrophy and adipose tissue noted. Patient presented with left hand Middle Interphalangeal joint contractures with inability to flex the MIP joints and hyperextension at digits 2-5 in a swan neck like deformity. Patient commented that she used her hand like a “spade”. The patient had a deep red color in her left hand compared to normal color in her right.
    • Palpation: Patient reported tender to touch upper trapezius muscles and levator scapular muscles at the left shoulder region. The infraspinatus and supraspinatus muscles were also tender to touch and patient reported reproduction of her pain in her arm that increased to a 8-9/10. The UT muscles were firm to the touch at the superior and superficial level and deeper to the first rib as well.
    • ROM: Seated cervical spine rotation was measured using goniometry with the axis positioned above the patient at the peak of the head/ occiput, the stable arm dissecting the patients thorax and the moving arm lined up with the patients nose and tactile cues to prevent compensatory thoracic rotation: Right rotation limited to 50 degrees and left rotation 46 degrees without pain. Patient demonstrated full flexion although reported 1/10 pain in her left shoulder at end range. No pain with cervical extension and lateral flexion was not assessed. Shoulder flexion was measured in sitting with the axis of the goniometer positioned on the lateral arm over the GH joint, the stable arm along the lateral border of the scapula and the moving arm along the midline of the humerus. Right GH flexion limited to 150 deg pain free, and left shoulder flexion limited to 135 with minimal movements of the scapula noted.
  • Management
    • The patient transitioned to supine and was unable to lie without a standard medium pillow under her head. PT palpated for the tender spots at the posterior neck, upper trapeziu s, SCMM, Levator scapulae, and scalenes. Tender points were found all along the upper trap on the left in isolation and compred to the the asymtomatic right side. Patient reported pain at levels 8-9/10 with palpation and reproduction of chief complaint at primary location and secondary location. Once PT obtained the most painful location, the proximal UT muscle at the posterior triangle of the neck, the area where the shoulder meets the neck, and the distal attachment at the the acromion, the PT used a pincer grasp to hold the muscle away from the neck to isolate the muscle belly and a Serin No.8 (0.30) x 50mm accupuncture needle was inserted from an anterior to posterior  direction with the inferior to superior angle. Multiple twitching was visible and palpable with the patient reporting peaks in pain with each insertion of the trigger point. The patient returned to sitting without any improvement reported. The patient transitioned to prone and the same size needles were inserted from a posterior to anterior inferior to superior angle with multiple twitching palpable. A second needle was inserted at the insertion of the Levator (medial superior border of the scapulae) and no twitching could be felt and no pain was reported. Continued palpation in the area revealed no reports of pain from the patient at the upper portion of the upper trapezius as well as the lower portion except at the are above the lower portion of the  levator, yet above the insertion point. An needle was inserted at a perpendicular angle with the supervision of a physician to insure safety of the lungs and nerves and a deep twitch was palpable and reproduction of the patients pain was reported. The patient transitioned to sitting and reported no pain in her primary area although reported a “fire” and “burning sensation ” into her symptomatic arm. Patient sat with ice applied to her treated area x 7 minutes and reported complete resolution of pain at her primary and secondary locations. The patients symptomatic hand  appeared equal in color to her uninvolved hand as well. The patient remained pain free at day 7.
  • Discussion
    • Myofascial pain syndrome which is a highly occurring cause of pain throughout the world. Chronic shoulder pain is common in patients following CVA., and is thought to be due to  muscle weakness and subluxation. Common treatments for myofascial pain including chronic shoudler pain after due to CVA consist mostly of conservative management including hot packs, cold packs, oral OTC medications such as NSAIDS, ibuprofin, and muscle relaxors, and physical therapy. Physical therapy interventions largely consist of stretching, manual therapy, massage, and modalities including TENS, ultrasound, hot packs, cold packs, and more recently dry needling. The second phase of treatment includes steroid injections, nerve blocks, and opiod medications. Tertiary interventions include surgery such as decompression  or tendon repair.
    • Dry needling has been shown to be an effective intervention for myofascial pain syndrome although is continues to be an underutilzed intervention in the USA. This may be due to the lack of exposure, political restrictions, education, or all of the above. There are no studies reporting the use of dry needling for chronicl shoulder pain after CVA. This case report introduces a new use of dry needling in physical therapy and rehabilitation and higher quality studies should be performed to identify this low risk, highly effective intervention.

Introduction:

  • Literature review
    • Myofascial pain syndrome which is a highly occurring cause of pain throughout the world. Chronic shoulder pain is common in patients following CVA., and is thought to be due to  muscle weakness and subluxation. Common treatments for myofascial pain including chronic shoudler pain after due to CVA consist mostly of conservative management including hot packs, cold packs, oral OTC medications such as NSAIDS, ibuprofin, and muscle relaxors, and physical therapy. Physical therapy interventions largely consist of stretching, manual therapy, massage, and modalities including TENS, ultrasound, hot packs, cold packs, and more recently dry needling. The second phase of treatment includes steroid injections, nerve blocks, and opiod medications. Tertiary interventions include surgery such as decompression  or tendon repair.
    • Dry needling has been shown to be an effective intervention for myofascial pain syndrome although is continues to be an underutilzed intervention in the USA. This may be due to the lack of exposure, political restrictions, education, or all of the above. There are no studies reporting the use of dry needling for chronicl shoulder pain after CVA. This case report introduces a new use of dry needling in physical therapy and rehabilitation and higher quality studies should be performed to identify this low risk, highly effective intervention.
  • Gap in body
    • A Search in Pubmed for Dry Needling AND shoulder pain Post CVA resulted in 0 articles
    • A Search in Pubmed for Dry Needling AND shoulder pain resulted in 17 articles, none reporting on post CVA shouler pain.
    • A Search in Pubmed for Shoulder pain AND CVA resulted in 360 articles, none reporting on the use of dry needling for shoudler pain post CVA
  • Interesting components of current case
    • The patient is highly educated (MD), employed, and functional with common symptoms of shoulder pain following a stroke. The patient is in the chronic phase of post CVA, who has had conventional treatments for her pain without resolution. The patient responded unusually well to a single physical therapy treatment using an underutilized intervention, namely dry needling.
  • Purpose of report
    • There are no articles discussing the use of dry needling or intramuscdular needling to address shoulder pain following CVA. This report will describe a single session of intramuscular dry needling to address chronic shoulder, arm, and hand pain following a CVA. This case report introduces a new use of dry needling in physical therapy and rehabilitation and higher quality studies should be performed to identify this low risk, highly effective intervention.

Case description:

    • History:A 71 year old female presented to physical therapy for an evaluation and treatment for her left scapular, shoulder, arm, and hand pain that had begun following a CVA 9 years prior. The patient had a medical history of diabetes mellitis, HTN, and dyslipidemia all for which she was medically managed. The patient described her CVA as “waking one morning with altered sensation in her left arm”. The patients showered and went to work with her symptoms worsening and so she drover herself to the ER where she was diagnosed with dangerously high B/P, and a CVA was suspected. The patient was referred for a CT scan which revealed a sarcoid lesion in her intrathoracic and abdominal region, which was successfully treated with a trial of prednisone. The patient reported few impairments following her CVA with left shoudler weakness and pain as her primary concern. The patient was referred to PT and reported that she was instructed to perform AROM and resisted shoulder exercise which increased her pain and resulted in a bad experience. The patient did not return to therapy. The patient received additional treatments for her pain including steriod injection and several nerve ganglion blocks which helped her pain somewhat. The patient was diagnosed with frozen shoulder although this was a questionable diagnosis made by a physical therapist in an informal examination and was not confirmed or treated.
    • Primary Complaint: The patient reported primary pain in her left scapular and shoulder area with secondary radiating pain in her arm and hand, occurring each day for the past 9 years although not all day. Patient reported that she was not aware of her pain while she was treating patients in her work as a psychiatrist. The patient rated her primary pain using the NPRS and VAS as 5-6/10 and her secondary radiating pain as 3/10 during the examination.
    • Observation: Patient presented with rounded shoulders, sacral sitting and mild to moderate posterior thoracic and scapular muscle atrophy and adipose tissue noted. Patient presented with left hand Middle Interphalangeal joint contractures with inability to flex the MIP joints and hyperextension at digits 2-5 in a swan neck like deformity. Patient commented that she used her hand like a “spade”. The patient had a deep red color in her left hand compared to normal color in her right.
    • Palpation: Patient reported tender to touch upper trapezius muscles and levator scapular muscles at the left shoulder region. The infraspinatus and supraspinatus muscles were also tender to touch and patient reported reproduction of her pain in her arm that increased to a 8-9/10. The UT muscles were firm to the touch at the superior and superficial level and deeper to the first rib as well.
    • ROM: Seated cervical spine rotation was measured using goniometry with the axis positioned above the patient at the peak of the head/ occiput, the stable arm dissecting the patients thorax and the moving arm lined up with the patients nose and tactile cues to prevent compensatory thoracic rotation: Right rotation limited to 50 degrees and left rotation 46 degrees without pain. Patient demonstrated full flexion although reported 1/10 pain in her left shoulder at end range. No pain with cervical extension and lateral flexion was not assessed. Shoulder flexion was measured in sitting with the axis of the goniometer positioned on the lateral arm over the GH joint, the stable arm along the lateral border of the scapula and the moving arm along the midline of the humerus. Right GH flexion limited to 150 deg pain free, and left shoulder flexion limited to 135 with minimal movements of the scapula noted.
  • Differential diagnosis
    • myofascial pain syndrome was suspected although consideration of alternate causes was considered including fibromyalgia, CPRS, RSD, and nerve damage, spasticity, neurological causes
  • Raw data

Management and outcomes

  • Plan of care
    • The patient was visiting her son from out of state and was present for a single session f of examination, evaluation and treatment if applicable
  • Actual care provided
    • The patient transitioned to supine and was unable to lie without a standard medium pillow under her head. PT palpated for the tender spots at the posterior neck, upper trapeziu s, SCMM, Levator scapulae, and scalenes. Tender points were found all along the upper trap on the left in isolation and compred to the the asymtomatic right side. Patient reported pain at levels 8-9/10 with palpation and reproduction of chief complaint at primary location and secondary location. Once PT obtained the most painful location, the proximal UT muscle at the posterior triangle of the neck, the area where the shoulder meets the neck, and the distal attachment at the the acromion, the PT used a pincer grasp to hold the muscle away from the neck to isolate the muscle belly and a Serin No.8 (0.30) x 50mm accupuncture needle was inserted from an anterior to posterior  direction with the inferior to superior angle. Multiple twitching was visible and palpable with the patient reporting peaks in pain with each insertion of the trigger point. The patient returned to sitting without any improvement reported. The patient transitioned to prone and the same size needles were inserted from a posterior to anterior inferior to superior angle with multiple twitching palpable. A second needle was inserted at the insertion of the Levator (medial superior border of the scapulae) and no twitching could be felt and no pain was reported. Continued palpation in the area revealed no reports of pain from the patient at the upper portion of the upper trapezius as well as the lower portion except at the are above the lower portion of the  levator, yet above the insertion point. An needle was inserted at a perpendicular angle with the supervision of a physician to insure safety of the lungs and nerves and a deep twitch was palpable and reproduction of the patients pain was reported.
  • Frequency of visits
    • The patient was treated during the initial session
  • Attendance
    • The patient was present for one session
  • HEP compliance
    • not applicable
  • Outcomes
    • The patient transitioned to sitting and reported no pain in her primary area although reported a “fire” and “burning sensation ” into her symptomatic arm. Patient sat with ice applied to her treated area x 7 minutes and reported complete resolution of pain at her primary and secondary locations. The patients symptomatic hand  appeared equal in color to her uninvolved hand as well. The patient remained pain free at day 7, and pain remians below a 3/10 at 60 days post treatment.
  • Discharge information
    • The patient was instructed to use ice as needed no more than 12 minutes at a time with instruction to place a thin sheet between the ice and her skin, to wait for numbness to occur and to stretch the UT several times a day

Discussion

  • Limitations
    • The limitations of this study include the inherent limitations of a case report, that is to say, it cannot be used to demonstrate any effectiveness, efficacy, or significance. Additionally, the details of the previous treatments are unavailable, nor the immediate results from the clinicians perspective. The patient and her husband, despite highly educated and of sound mind, are sure to have forgotten the details of treatments, some of which have occurred as long as 9 years prior. Finally, the patient may not reflect the usual patient with shoulder pain following stroke since she continues to work in a field that does not require constant use of he non-dominant hand.
  • Adds to body of knowledge
  • Relates to current research
  • Novelty points
  • Future studies

Conclusion

Acknowledgments

Patient consent

Tables

  • Study 1: Summary.-This study investigated the prevalence of pain in the ipsilateral upper-limb in stroke patients. 229 stroke patients (133 men, 96 women; M age = 59.0 yr., SD = 12.4) were assessed with the Pain Behaviors Scales and their motor weakness was measured with the Motricity Index. Results indicated that over 27% of patients experienced pain in at least one joint of the ipsilateral upper limb. Shoulder pain was the most common. Further analysis indicated that the occurrence of pain in the ipsilateral upper limb was higher among women, among patients who used a cane, and among patients with a greater weakness of the affected lower limb. (Percept Mot Skills. 2014 Nov 11. [Epub ahead of print]
  • PREVALENCE AND DETERMINANTS OF PAIN IN THE IPSILATERAL UPPER LIMB OF STROKE PATIENTS .

  • Kwon YH1, Kwon JW, Lee NK, Kang KW, Son SM.)
  • Study 2-Abstract
  • OBJECTIVE:

  • To provide an epidemiological perspective of the clinical profile, frequency, and determinants of poststroke hemiplegic shoulder pain.
  • DESIGN:

  • A prospective population-based study of an inception cohort of participants with a 12-month follow-up period.
  • SETTING:

  • General community and hospital within a geographically defined metropolitan region.
  • PARTICIPANTS:

  • Multiple ascertainment techniques were used to identify 318 confirmed stroke events in 301 individuals. Among adults with stroke, data on shoulder pain were available for 198 (83% of the survivors) at baseline and for 156 and 148 at 4 and 12 months, respectively.
  • INTERVENTIONS:

  • Not applicable.
  • MAIN OUTCOME MEASURES:

  • Subjective reports of onset, severity, and aggravating factors for pain and 3 passive range-of-motion measures were collected at baseline and at 4- and 12-month follow-up.
  • RESULTS:

  • A total of 10% of the participants reported shoulder pain at baseline, whereas 21% reported pain at each follow-up assessment. Overall, 29% of all assessed participants reported shoulder pain during 12-month follow-up, with the median pain score (visual analog scale score=40) highest at 4 months and more often associated with movement at later time points. Objective passive range-of-motion tests elicited higher frequencies of pain than did self-report and predicted later subjective shoulder pain (crude relative risk of 3.22 [95% confidence interval, 1.01-10.27]).
  • CONCLUSIONS:

  • The frequency of poststroke shoulder pain is almost 30%. Peak onset and severity of hemiplegic shoulder pain in this study was at 4 months, outside of rehabilitation admission time frames. Systematic use of objective assessment tools may aid in early identification and management of stroke survivors at risk of this common complication of stroke.
  • To assess the relative effectiveness of three injections methods suprascapular nerve block (SSNB) alone, intra-articular steroid injection (IAI) alone, or both-on relief of hemiplegic shoulder pain.
  • METHODS:

  • We recruited 30 patients with hemiplegic shoulder pain after stroke. SSNB was performed in 10 patients, IAI in 10 patients, and a combination of two injections in 10 patients. All were ultrasonography guided. Each patient’s maximum passive range of motion (ROM) in the shoulder was measured, and the pain intensity level was assessed with a visual analogue scale (VAS). Repeated measures were performed on pre-injection, and after injection at 1 hour, 1 week, and 1 month. Data were analyzed by Kruskal-Wallis and Friedman tests.
  • RESULTS:

  • All variables that were repeatedly measured showed significant differences in shoulder ROM with time (p<0.05), but there was no difference according injection method. In addition, VAS was statistically significantly different with time, but there was no difference by injection method. Pain significantly decreased until a week after injection, but pain after a month was relatively increased. However, pain was decreased compared to pre-injection.
  • CONCLUSION:

  • The three injection methods significantly improved shoulder ROM and pain with time, but no statistically significant difference was found between them (Ann Rehabil Med. 2014 Apr;38(2):167-73. doi: 10.5535/arm.2014.38.2.167. Epub 2014 Apr 29.
  • The Comparison of Effects of Suprascapular Nerve Block, Intra-articular Steroid Injection, and a Combination Therapy on Hemiplegic Shoulder Pain: Pilot Study.

  • Jeon WH1, Park GW1, Jeong HJ2, Sim YJ2.)
  • he aim of this study was to evaluate the ultrasonography (US) and MRI findings in hemiplegic patients with shoulder pain and investigate the correlation between them. It is not possible for these patients to fully perform active range of motion (ROM) and stress tests, so imaging methods take center stage in diagnosis and treatment planning.
  • MATERIALS AND METHODS:

  • A total of 68 hemiplegic patients with shoulder pain attending the inpatient rehabilitation program were included in the study. MRI and US results from the patient files were recorded. The frequency of each pathology identified by US and MRI was determined. The distribution of MRI and US findings was investigated to see whether there was a statistical difference between the correlation of MRI and US results.
  • RESULTS:

  • The mean (SD) age of the patients was 63.7 (8.3) years and the mean (SD) duration of hemiplegia was 49 (8.9) days. According to the MRI results, glenohumeral and acromioclavicular joint degeneration was found in 77.9% and 79.7% of the patients, respectively; subacromial-subdeltoid bursitis in 80.9%; fluid increase in the joint space in 41.2%; supraspinatus tendinitis in 36.8%; and supraspinatus partial rupture in 33.8%. Shoulder US findings were supraspinatus tendinitis in 54.4%, acromioclavicular joint degeneration in 26.5%, bicipital tendinitis in 20.6%, and subacromial-subdeltoid bursitis in 19.1%. There was a statistically significant difference between MRI and US findings. The results were not compatible with each other (P ≯ .05), and these findings were not consistent with each other since the kappa coefficient was under 0.40 for all these results.
  • CONCLUSION:

  • Although US is recommended as the first method in determining shoulder pathologies in hemiplegic patients, we suggest that MRI should be used as the first choice in hemiplegic patients with shoulder pain. MRI and US findings were not consistent, and US is dependent on the experience of the operator. MRI should be the first choice in cases where the diagnosis will affect the treatment choice due to the lack of correlation between US and MRI findings (Top Stroke Rehabil. 2014;21 Suppl 1:S1-7. doi: 10.1310/tsr21S1-S1.
  • Ultrasound and magnetic resonance findings and correlation in hemiplegic patients with shoulder pain.

  • Doğun A1, Karabay İ1, Hatipoğlu C2, Özgirgin N1.)
  • This case report describes a 48-year-old female who presented with complaints of right shoulder pain, hyperesthesias and swelling of the hand along with added symptoms of pain centralization following a cerebrovascular accident. On clinical evaluation, the patient satisfied the Budapest diagnostic criteria for Complex Regional Pain Syndrome (CRPS) type-1. Physical therapy management (1st three sessions) was initially focused on painneurophysiology education with an aim to reduce kinesiophobia and reconceptualise her pain perception. The patient had an immediate significant improvement in her pain and functional status. Following this, pain modulation in the form of transcutaneous electrical nerve stimulation, kinesio tape application, “pain exposure” physical therapy and exercise therapy was carried out for a period of 7 weeks. The patient had complete resolution of her symptoms which was maintained at a six-month follow-up (Physiother Theory Pract. 2014 Jan;30(1):38-48. doi: 10.3109/09593985.2013.814186. Epub 2013 Jul 23.)

BellairePT

Bellaire Physical Therapy

Abraham Lieberman, PT, DPT

Doctor of Physical Therapy

5420 DASHWOOD, SUITE 306

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