Volume 2, Number 4 | Winter 2007

Clinical Report 1 (Japan)
A Case of Acupuncture Treatment for Left Shoulder Pain
Thought to be Caused by Neuralgic Amyotrophy
Noriko Hori,1),2), Hitoshi Yamashita,3) Hiroshi Tsukayama1)
1) Tsukuba University of Technology
2) University of Tsukuba3) Morinomiya University of Medical Sciences

About Our Clinic
The Center for Integrative Medicine of theTsukuba University of Technology (formerly, theTsukuba College of Technology Clinic) is an
outpatient clinic for both conventional medicine andtraditional medicine that was established in April,
1992. It has 2 sections: the Conventional MedicalClinic and the Acupuncture and Moxibustion Clinic.
In the latter section, we perform acupuncture
treatment for outpatients as well as bedsidelearning for the college students and acupunctureinterns. In the Conventional Medical Clinic, we offer
consultations in 5 specialties, Kampo medicine,orthopedics, neurology, radiology and pediatrical.
Between April 1992 and March 2005, 9665
patients (4086 men and 5579 women) visited theAcupuncture and Moxibustion Clinic. During thisperiod, 146 acupuncturists (18 instructors and 128
interns) participated in 132359 acupuncture
sessions. The types of acupuncture differed between
acupuncturists and included electroacupuncture,
modern medical acupuncture, meridian therapy,and moxibustion (direct or indirect). At theAcupuncture and Moxibustion Clinic we treatedmainly musculoskeletal pain or discomfort (82.4%);
otherhealthproblems
treatedincluded
gynecologicalandobstetrical(2.5%),
otolaryngological(2.4%),
circulatory(1.1%),
respiratory (1.0%), fatigue and tiredness (1.0%),
neurological (0.9%), ophthalmological (0.9%). Thispattern of acupuncture use in our clinic may reflect
the current pattern of acupuncture use in Japan.
However, even in Japan, it is rare that a clinic of anational university corporation provides more thanhalf of its patients with acupuncture treatment.
Keywords: neuralgic amyotrophy, suprascapularnerve disorder, axillary nerve disorder, acupuncture,shoulder pain
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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 2, Number 4 | Winter 2007

I.

Introduction

Before onset she had not sustained any external
withinjuries or fever. The only possible cause she could

limitation of motion is caused frozen shoulder,

identify was that 1 week before the onset of thesubacromial bursitis, tendinitis, calcific bursitis anddisease she had spent some time in a very coldso on. These conditions may also cause, depending

air-conditioned room.

on the contracture or affected site, muscle atrophy[Anamnesis] Nothing of particular noteor reduced muscle power. Neurological disorder is[Complications]

Generally,shoulderpain

associatedgenerally not included. Reasons for alleviation of

The patient has diabetes, but it is controlled at aordinary

different hospital by diet alone. She has someacupuncture treatment may include (1) natural

hypertension but has not been prescribed any

course of the disease itself, (2) changes due to otherhypotensives. At another clinic, Hachimijiogan andtreatment modalities or variations in lifestyle, (3)Kamishoyosan were prescribed for climactericnonspecificsymptoms.

symptoms

duringeffects

thebasedcourseonofexpectationsorassumptions, (4) total sum of effects brought about[Family History] Mother has diabetes.

by[Patient Profile]theacupuncture

treatment,(5)

excessive

evaluation of the effects of the acupunctureThe patient is married and has 2 children. She

treatment during daily practice. Regardless ofengages in volunteer work and goes to Tai Chi andwhether the condition improves or deteriorates,

dancing practice 3 times a week.

most of the diseases for which the influence of the[Present Status]

acupuncture treatment tends to be excessively
evaluated recover spontaneously, such as theHeight: 150 cm; weight: 42 kg; blood pressure:156/96 mmHg; pulse 60 bpm.

well-known example of Bell's palsy. Here, we would

The patient was worried that the pain andlike to report a case in which we observed the entire

chilling of the shoulder might be related and thus

course in a patient treated with acupuncture forrefused to uncover the entire shoulder girdle forshoulder pain thought to be caused by neuralgic

examination.

amyotrophy and in which neural damage-induced

The range of motion (ROM) of the left shoulder

atrophy and loss of muscle power were also

joint was 135° flexion, 30° extension, and 40°

observed.
II. Case

external rotation; during a (posterior) belt-tying

Patient: 55-year old woman; first visit on August 17,

thoracic spinous process (on the right side of the 6th1992; chief complaint: left shoulder pain

thoracic spinous process), and during a hair-tying

motion the left thumb reached the height of the 8th

motion the left thumb reached the height of the 1st[Present Illness]thoracic spinous process (on the right side of the 3rdThree days before her 1st visit to our clinic andthoracic spinous process). Restriction of the ROM

before going to bed, the patient suddenly fell pain in

was in any position due to pain; contraction was not

the lateral left shoulder. The pain during that nightobserved.

was so severe that it prevented the patient from

The patient denied feeling heat or swelling in thelying down and thus forced her to spend the night inleft shoulder. Tenderness was found at LI15 anda sitting position on a sofa. Whist the pain was

TE14 as well as in the deltoid muscle area but waspresent during both rest and movement, the mostnot very marked. Tenderness was not observed in

comfortable position was with the arm hanging

the intertubercular groove, nor over or around thedown, and the pain subsided slightly during the day.

coracoid process. Palpation revealed an increased

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

15Volume 2, Number 4 | Winter 2007

tonus of the ascending part of the trapezius muscle.
The ROM of the neck was normal, whilst theSpurling test (pain radiating to the entire left arm)and the Morley test (numbness radiating to the leftarm) were positive on the left side.
Biceps and triceps brachii muscle reflexes werenormal.
[Auxiliary Diagnosis]
An orthopedist of our center did not detect anyanomalies on X-ray films of the shoulder joint(Figure 1). X-ray films of the cervical vertebrae
showed degeneration of the C5/6/7 intervertebral
discs (Figures 2 and 3). However, according to theorthopedist of our center, the degree of thesechanges was unlikely to be responsible for thesensory disturbances. Furthermore, an evoked
electromyogram(EMG)

obtainedfrom

thesuprascapular nerve showed a prolongation of theM-wave latency for the left supraspinatus muscle.

Figure 3[Course]Table 1 shows the variations in the pathologicalcondition as well as the main symptoms andfindings.
During the first visit we assumed that thecondition originated from the cervical spine. On thebasis of the findings of pain at rest, during motion,
and at night, and of the pain induced by restriction offlexion and abduction, the lack of any feeling of heat,and the age of the patient, we assumed that the pain
was probably due to a frozen shoulder. Acupuncture
treatment consisted of needling the region of theshoulder joint to a depth of approximately 10 mm
and retaining the needles for a certain period of time.
Stainless steel 50-mm No.18 or 50-mm No.20 needles(K-type：Seirin) were used. Moreover, from August 18
to August 20 diclofenac sodium (proprietary name:Voltaren) was prescribed as additional treatment by

Figure 1

the clinic in our center, with addition of diclofenac
sodium suppositories (25 mg) on August 20, and thisprescription of diclofenac sodium and diclofenac
sodium suppositories was continued until August 27.
At the second (August 20) and third (August24)

visits,treatment

consistedofretaining

needles and manual needling at GB 22、LI 15、TE
14 and in the axilla. The pain-induced limitationof shoulder motion immediately disappeared, butthe resting pain remained as severe as before.
However, the patient reported that when she woke up
Figure 216

on the morning of August 30, the pain had
disappeared and subsequently so had the night pain.
The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 2, Number 4 | Winter 2007
Table 1 Changes in symptoms, findings and assumed pathology
Symptoms
First visit (92/8/17)

night pain, pain at rest,

Findings

Assumed pathology

pain during movement： flexion, external rotationso-called frozen shoulder

Spurling test, Morris test (+)

pain during movementorWBC: 3,500/mm3 CRP: (-)

cervical spondylosis

pain during movement: flexion, external rotation
2nd (8/20)

as aboveetc.

inflammation of rotator cuff

Tenderness: LI 15, TE 14orplain x-ray of the shoulder joint: within normal limits

subacromial bursitis

muscle tension: M. trapezius

shoulder stiffness

pain alleviated,
4th visit (9/1)

shoulder stiffness,heaviness of theshoulders

muscle atrophy: left subscapularis

difficulties elevating
6th visit (9/18)

left shoulder,heaviness of thesuprascapular nerve entrapment

muscle weakness: abduction, external rotation

shoulderssensory disturbance: dullness from lateral left upper arm to the region posterior
9th visit (10/9)
11th visit (11/2)
26th visit (93/4/9)

to the shoulder

as abovesuprascapular nerve lesion

plain x-ray of cervical vertebrae: disk degeneration at C5/6/7

orevoked electromyogram: decreased conduction velocity of suprascapular nerve

axillary nerve dysfunction

heaviness of themuscle atrophy: left subscapularis

possibility of neuralgic amyotrophy

shoulderssensation: no differences between left and rightas aboveshe

Because of the patient’s feeling easier after thecomplained of a persistent dull heaviness in theacupuncture treatments and because of her fear ofshoulder.

recurrences, we continued the treatment until JuneAs

shecontinued

treatment

thereafter,

Examination of the area extending from the back

1993, performing approximately 30 treatments,

to the arm on the sixth visit (September 18)

after which slight heaviness in the shoulder still

revealed a marked atrophy of the left infraspinatus

remained.

muscle, loss of power, and difficulties in raising herarm. We suspected that this was due to anIII. Discussion

entrapment neuropathy of the suprascapular nerve,

According to an investigation by Alfen et al.1)

so we targeted our needling at the regions of theneuralgic amyotrophy can be classified as idiopathic

suprascapular notch and the supraspinatus andor hereditary, either of which types involves pain

infraspinatus muscles. Moreover, we also instructed

calledthe patient to exercise the involved muscles athome.
During the ninth visit (October 9), hypesthesia
and hypalgia in the region from the left lateral
upper arm to the posterior region of the shoulder
joint (innervation area of the axillary nerve or thefifth cervical nerve) were observed.
Later, the sensory disturbance disappeared and aNAattacks(verysevere,relentlessneuropathic ‘NA pain’) that continues for a period ofa few days to several weeks in the early phase of theonset and is particularly frequent during thenight.1) Recurrent attacks may also occuer.1) In mostcases, the pain occurs unilaterally in the upper
extremities but bilateral occurrences have alsooccasionallybeenreported.1)

Othersymptomsrecovery of muscle power was observed, but theinclude hyperesthesia and paresthesia, often seen in

feeling of dull heaviness in the shoulder continued

the trapezoid muscle and on the lateral arm.

and the atrophy was present to the same degree as

Following these symptoms, paresis and muscle

that of the sixth visit.

atrophy may develop.

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

Muscles pronetothe17Volume 2, Number 4 | Winter 2007

development of these symptoms include mainly theshoulder to the lateral upper arm, as indicated byinfraspinatus, serratus anterior, supraspinatus, andthe prolonged latency in the M-wave of thethe muscles of the upper trunk and arm.1) Moreover,supraspinatus muscle. We suggested that this was aanomalous findings of EMG in many patients werecasealso observed.1) A combination of NSAIDs andprolonged and persistent to be heaviness in theopiates has been most effective for the pain, whilst

shoulder remained after the pain had subsided inother drugs are much less effective.1) For many

the long term.

ofneuralgic

amyotrophy.

Moreover,thepatients the prognosis includes residual severe

During the early phase in this patient, the effects

neuropathic stabbing or shooting pain and persistedof needling for the shoulder pain with limitation of

musculoskeletal pain that often continues formotion were immediately reproducible after theseveral years after the NA attacks have subsided.1)

needling at the second and third visits. So weIn Japan, limitation of motion induced by pain

thought needling to be useful for the relief of thehas been treated as a variety of pathologicpain. However, in this case the night and restingconditions.

representative

pain suddenly disappeared between the third andclassification2) which is used in Japan for painful

fourth visits. Leading us to conclude that this effectshoulder with limitation of motion.

was unlikely to have been brought about by theTable

2showsaTable 2 Classification3) of painful shoulder joint arrest in Japan
Coracoiditis
Inflammation of biceps brachii
tendonCalcific inflammation of therotator cuff
So-called frozen shoulder

Subacromial bursitis

Inflammation of the rotator cuff

Rotator cuff tear

Impingement syndrome

acupuncture treatment. Instead, alleviation of theshoulder pain whilst not in except during motion
and recovery of muscle strength and sensation were
probably due to the natural course of the neuralgic
amyotrophy.
Since

theearly

symptoms

ofneuralgic

amyotrophy generally resemble diseases of theshoulder joint, it is often carelessly treated

In the case described here, a comprehensive

continuously

asfrozenshoulder,tendinitis,observation and detailed examination during thecalcific bursitis, and so on. Alleviation of the pain

initial phase of the treatment was not performed

during the natural course may be evaluated as thebecause of the patient’s severe pain and refusal toeffect of the acupuncture treatment. In Japan, forexpose the shoulder region based on her fear ofacupuncturists cannot perform diagnostic imaging

chilling. For this reason, the pathology of theor blood tests, so pathological conditions have tocondition could not be correctly identified during thebeearly stage, so that the considerations of thebecause we initially did not examine the shoulder

pathology changed again and again. However, onand upper back in this patient, we missed many

the whole the severe pain of unknown origin andrelevant

sudden onset resolved spontaneously after a few

amyotrophy

differs

days without pharmacologic intervention. The

tendinitis

andsymptoms of this case progressed to later atrophy ofacupuncture treatment for patients with shoulder

the infraspinatus muscle and reduced muscle

painshouldsuffice,butstrength for abduction and external rotation, as wellacupuncturists

shouldpromptly

as to hypesthesia extending from the posteriorpatients to a specialist.

18

identifiedbybedside

findings.

Givenfromruns

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

findings.

thatfrozenaHowever,neuralgicshoulder

different
whenorcourse,

indoubt,refertheseVolume 2, Number 4 | Winter 2007

IV. SummaryReferences

1)

1)

2)

We performed acupuncture treatment for leftshoulder pain of sudden onset.

clinical spectrum of neuralgic amyotrophy in

It is highly possible that this was a case of

246 cases. Brain 2006; 129:438-450.

neuralgic amyotrophy.
3)

Nens van Alfen，Baziel G.M. van Engelen. The

2)

In the early stage, the acupuncture treatment

Katsuya Nobuhara: Shoulder – Function andClinics, Sec. Ed., Tokyo 1987

in this patient was effective for the pain duringmotion.
4)

In this case, the acupuncture treatment seemed
to have been effective in alleviating the night
pain and resting pain and in recovering muscle
strength and sensation, but these changes weremore likely due to the natural course of theneuralgic amyotrophy.

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

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