Volume 8, Number 1 | Spring 2013

Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (7) – OrthopedicDisorders, D Acupuncture Research for Stiff Shoulders

Tomokazu Kikuchi

Center of Oriental Medicine
Saitama Medical University Hospotal

The 2010 National Lifestyle Survey1) found that
Stiff Shoulders were the number one complaint for

presents with organic disease symptoms, if there are
no objective shoulder stiffness findings, it is labeled“Psychogenic Shoulder Stiffness”. In this paper, we
will be discussing shoulder stiffness that is not theresult of critical changes due to diseases orconditions that cannot be confirmed as neurologicalabnormalities.
1. Pathophysiology of Stiff Shoulders

women and the number 2 complaint for men, with

Until recently, the pathophysiology of stiff

more than 90% of the population having had

shoulders has been categorized as follows: instability

experience with the condition. However, medicallyof the cervical intervertebral discs, local tension in

speaking, Stiff Shoulders are a subjective complaint

the sympathetic nervous system and additionally,

with no clear definition. Further, in 2004, a study forcirculatory disorders influencing the nerves andorthopedic“StiffShoulder

muscles. On the other hand, as for neck pain, causes

subjective

physicalhave been hypothetically explained as due excessive

symptoms including muscle tension and stiffness

muscle stimulation causing excessive tension in(Korikan) extending from the neck to the scapularintervertebral joints, cervical discs or nerve roots as

area, characterized by a sense of pressure andthey relate to referred pain. Additionally, it is often

dullness, but presented no clear definition ofthought that shoulder stiffness is a condition with

objective findings. Stiff shoulders are often said to bemostly non-specific symptoms involving a viciousa uniquely Japanese symptom but epidemiologicalcycle of pain compounded by additional psychologicalcomparisons between the United States and Europeand sociological factors2).

Research

physiciansProject”2)

calledfoundfor [neck pain] and [stiff shoulders] found these
symptoms distributed within and between different
age groups and across gender lines. On the other
hand, according to a National Survey (multiple
answers possible) of people who sought treatment for
stiff shoulders 24.6% went to hospitals, 20.1% wenttoclinicsand59.6%

wenttoacupuncture,moxibustion and massage practitioners. Clearly alarge proportion of the population are receiving
treatment from Acupuncture, Moxibustion andMassage.

Classical

Oriental

Medicaltheorydescribes damage by cold in the neck, shoulders,
upper back leading to stiffness and pain.
Within the field of Pain Clinics, stiff shoulder isdivided into three categories. The first has no clear
pathology and is referred to “Essential ShoulderStiffness”. The second type may arise from spinal
disorders or underlying shoulder disorders and isreferred to as “Symptomatic Shoulder Stiffness”.
Finally, regardless of whether or not the patient2

2. Acupuncture Treatment for Stiff Shoulders
With the exclusion of the psychological andsociological background attached to stiff shoulders,the functional abnormalities seen in the sympathetic
nervous system, circulatory disorders influencing
the muscles and nerves begin to form a clearer
clinical picture. For the purposes of Acupunctureand Moxibustion treatment, keeping in mind thepossibility of stimulating the subcutaneous tissues,
we can anticipate effects in the skin, muscles, fascia,
intervertebral joints and the peripheral nerves. It
has been estimated that the effects of acupuncture
are due to improved circulation in muscles andnerves 3) and may be due to normalization of theautonomic nervous system mediated by higher levelsof the central nervous system. The principle areas
for stimulation are along the back of the skull,
trapezius muscles of the neck and head and semispinalis muscle of the head (UB10, GB20), theThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 1 | Spring 2013

insertions of the Sternocleidomastoid and theinvestigate which tissues will be stimulated beyond

Splenius muscles of the head (GB12), on the upper

theportion if the Trapezius (GB21), muscles that cross

Additionally, the problem now is that, even if shamalong the inter-scapular area (UB43), also, areas ofacupuncture is used as a placebo control, it has been

the Splenius and the Scapulae Levator and theshown to have a physiological stimulus. From now,insertion of the Splenius at the superior border of thewe must investigate the causes of Shoulder Stiffness,

scapula (SI14). Common methods of stimulation

how to conduct acupuncture to stimulate specificinclude embedded needles, manual stimulation oftissues and to grasp how this stimulation effects thefiliform needles, and electro-acupuncture. It isdisease process.

necessary to pay careful attention to the patient’s
condition and level of pain so that the stimulation
can be appropriately adjusted.

superficial

pre-determinedacu-point.

4. Characteristics of Shoulder Patients and ClinicalStatusCompared to Westerners’ “Stiff Neck Pain“,

3. Acupuncture and Moxibustion Treatment for Stiff

Japan’s stiff shoulders represent deeper psycho-Shoulders–The Condition of Research Abroadsocial stress. Japan’s Historical and Cultural

We performed a literature review of clinical trials

background are thought to have been influential inon the effectiveness of Acupuncture and Moxibustion

the development of this uniquely Japanese shoulder

Therapy for Stiff Shoulders conducted by foreign

stiffness. The consensus is that Japanese culture

researchers.「PubMed」was used as the dedicatedavoided, as much as possible, descriptions ofData Base for the literature review.

psychological symptoms that appeared, instead,included[neckstiffness],pain],[shoulder[neckKey Wordsdisorders],stiffness],[neck[acupuncture],focus was placed on their physical representation. To
betterunderstandtheclinicalefficacyof[moxibustion], [randomized controlled trial]. We are

Acupuncture treatment for Stiff Shoulders wereporting on basic research and original content

conducted a Literature Search. Using a database ofstandards. Our exclusion criteria eliminated reviews

prominent Medical School Journals including theand commentaries from this report. We found 23

following keywords: Stiff Shoulders, Neck Pain,

reports that could be included. Evaluation methodsAcupuncture,included mostly VAS scores, NDS and SF-36 wereControlled Trials. The search provided 4 appropriate

also seen here and there. The most common type ofreferences. Nakajima5) compared a local pain relief

control was a “no treatment” control group, placebo

injection group with an acupuncture group. Reportedcontrol (non-meridian acu-points or skin stimulation

results showed that for neck pain, acupuncturegroups).TENS groups and massage groups were also

treatment was more effective in the short term andused as comparative control groups. Compared to theover the long run, so compared to other treatment“noacupuncturemethods, acupuncture was more effective. Nabeda ettreatment could be accepted as a valid treatment

al. compared the superficial needle only andmethod. However, when compared with placebos orretaining needle after the needling sensations at theother treatment-type controls, the point of view

tender point, no difference was found within andabout acupuncture efficacy was not unified. Thisbetween groups after 1, 2, 3 weeks. Furuya et al., 7)

paper is targeted to non-specific shoulder problems

investigated using 0.6mm embedded needles and(stiffness); as there are a variety of locations andplacebo type embedded needles (using just thecauses of shoulder pain (work related, postureprotective tape), comparing the baseline to post-

related,stimulationtreatment”

etc.).

acupuncture

control

Althoughisgroups,thearea3-dimensional,

treated byfew

reports

Moxibustion,readings

andand3days

Randomized

after

thestimulation, they found that the subjects with true

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 1 | Spring 2013

embeddedneedlesexperiencedsignificant

5. Future Prospects

improvement. Further, comparing positive andRather than treat stiff shoulders as simply anegative results of a load test on the cervical spine,

symptom, we consider it necessary to assess thewhile groups testing intervertebral joints and discs

exact background factors to grasp underlying

demonstrated no changes is test results, it was

disease processes and clarify which tissues are being

reported that in test groups for muscles and fascia,

over-stimulated by life style factors and which areas

test changes were effectively confirmed. On the otherneed to be treated to return the body to normal

hand, Ito et al.8) used a Trigger Point (TP)function. We suggest performing comparative trials,Acupuncturegroupanda

Standardized

Acupuncture group, comparing these to shamacupuncture, after the treatment they reported that
only the TP group’s VAS scores dropped significantly.
Because the research subjects were students andfaculty

members,

consideredtoa“volunteerbias”

certaindegree.

shouldbeHowever,acupuncture treatment for stiff shoulders bytreating muscles and fascia was found to be highly
useful compared to treating with TP or the cervicalspine.

if possible, by separating subjects into specificgroups based on their personal reports, clinicalfindings and discrepancies between these. For
example, dividing subjects into groups with personal
pain reports (specific pain in a localized area) thatcoincide with clinical findings or a group with pain
(non-specific pain) that conflicts with clinical finding.
These subgroups with shoulder stiffness complaints
could then be compared using tests that provide
reproducible results (such as localized pressure painat specific points of the joint, range of motion andmuscle strength tests). Concerning evaluation
methods, beyond the VAS pain indicator, QOL scaleswith multi-faceted questions and possible responses
should be used. We have already been developing aTable 6: The change of acupuncture before and after with SF
─36 and WAI by acupuncture treatment

non-specific task score/ protocol based on Furuya etal.’s work with embedded needles for VDT workers
with non-specific shoulder pain. So for subjects with

BeforeAfter
1 month

P value

Mental Component Score

51.3±6.3

53.1±5.8<.0001

measures to clarify the usefulness of acupuncture forPhysical Component Score

44.0±10.047.2±8.5<.0001

improving work effectiveness9,10) and align the

Physical functioning

53.6±6.4

54.0±6.4.5998

treatment with background factors that may be

Role physical46.4±10.6

48.9±7.0.0167

causing shoulder pain (Table 6). On the other hand,

Bodily pain

42.4±9.0

48.9±9.0＜.0001the most significant problem has become using

Vitality

48.5±9.0

50.5±8.0.0714“sham”

General health perceptions

44.7±10.1

46.7±9.2.1286

Social functioning

50.5±9.7

50.7±7.4.9709

Role emotional48.9±9.749.1±9.4.8434

an acupuncture point has been shown to activate

Mental health47.2±9.1

48.9±8.0.1134

Polymodal receptors in the epidermis, so using

Work ability index

36.1±6.5

37.4±5.7.0058

normal filiform needles (豪鍼) for sham needling was

Wilcoxon lunk sine test, n=61, mean±S.D.

shoulder pain, we used VAS and QOL (SF-36)

acupuncture

whenestablishingthecomparison groups for acupuncture. So far only
embedded needles have been considered appropriate
because even the mere application of a guide tube toconsidered unrealistic. At present, comparison withother treatments and acupuncture stimulation site4

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 1 | Spring 2013selection methodologies, acupuncture RCTs should
be used to investigate the specific effects of background factors on shoulder pain. In the future,
multifaceted evaluation results should be used todetermine what back ground factors contribute tostiff shoulders, Acupuncture RCTs should becompared with other treatments and point selection
methodology should be investigated to achievespecific effects.
References
1)

MinistryofHealth,LaborandWelfare:Overview of the national livelihood Census,2006, 2007.
2)

Kenji Takagishi et al.: Research Project on theShoulder (2004-6). Japan Society of Orthopedic
Surgery 82(10): 901-911, 2008

3)

Tomokazu Kikuchi et al.: Effect of electroacupuncture stimulation on circulation to thetrapezius muscle─ 99mTcO4 ─A study using theclearance method. Kampo Medicine 61(6): 834839, 2010

4)

Satoshi Yamaguchi: Effects of Acupuncture
Treatments: Trends in Research Findings. The
Journal of the Japanese Society of Balneology,
Climatology and Physical Medicine58 (4): 232240, 1995

5)

Miwa Nakashima et al.: Study on acupuncture forneck pain by a randomized, controlled trial withlocal injection. Journal of Japan Society ofAcupuncture and Moxibustion 57(4): 491-500, 2007
6) Tomoyuki Nabeta et al. Randomized controlled
pilot study of acupuncture on neck stiffness.
Journal of the Japan Society of Acupunctureand Moxibustion; 47(3): 173–81, 1997
7) Eiji Furuya, et al.: The Effects of Thumbtack
Needling on Upper Back Muscle Stiffness,
Journal of Japan Society of Acupuncture andMoxibustion, 52 (5): 553-561, 2002.
8) Kazunori Ito et al.: Trigger point acupuncture
trials on University students with shoulder
stiffness─A Questionnaire Survey from theresults of Acupuncture Clinical trials. Journal ofJapan Society of Acupuncture and Moxibustion
56(2): 150-157, 2006
9) Rika Suzuki et al.: Effects of Acupuncture for
VDT workers (1) Influence on Neck, Shoulder
Stiffness and Eye Strain. Journal of Japan
Society of Acupuncture and Moxibustion 60(5):829-836, 2010
10) Tomokazu Kikuchi et al.:Effects ofAcupuncture for VDT workers (2) Influences on
QOL and Work Productivity and Comfort.
Journal of Japan Society of Acupuncture andMoxibustion 61 (1): 51-58, 2011

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