Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

Clinical Application:
Stress and Shoulder Stiffness

understoodand regardless of whether he recognizes this or not,will suffer from stress induced mental and physicalfatigue. Stressors are influenced by both the physicaland mental aspects of our living environment, where asomatic reaction to stress could be the development of
duodenal

ulcers,gastrointestinal

discomfort, or similar symptoms related to thedigestive

organs,hypertension

andsimilarcardiovascular symptoms, headache, shoulder stiffness,dizziness, easy susceptibility to catching cold andsimilar indefinite complaints, cerebral stroke orintracerebral hemorrhage, myocardial infarction, andlike problems. Moreover, diabetes or obesity andsimilar lifestyle-related diseases are also included inthis category and considered to be possible etiologic
factors or exciting causes.
While under stress many people also suffer frompsychological

as

the

outwardresponse to negative stimulations affecting both mind

Modern man is subjected to a wide variety of stress,

andinterpreted

manifestation of "physically strained conditions" in

I. Introduction

gastric

iftroubles.

Motivation,

vitalityand body. Specifically, this refers to physical tension or
stiffness, or on the contrary, may also mean the lack oftension. This represents the conditions of deficiency orexcess as they are identified by palpation in oriental
medicine. The stress concept put forward by Selye may,in fact, be considered to be very close to the oriental
medical concept of mind-body unity.
If a person becomes stressed, the site where thisperson feels to be afflicted. (i.e., where the stress finds
its physical manifestation), differs among people andcountries. In Japan, these conditions generally become
manifest in the form of "shoulder stiffness" marked
mainly by tensioning of the shoulders (trapezius
muscles).

TheshoulderstiffnesstheJapanesecomplain about should be understood in this context as
a distorted condition characterized by both physicaland mental problems.
1. What is shoulder stiffness?

and"Kata-Kori, or shoulder stiffness" refers to an

perseverance may be reduced. Afflicted persons could

increased tension and therefore hardening of thetend to brooding and often develop depressive moods. A

shoulder muscles that is felt as pain or discomfort.

marked feeling of exhaustion is then experienced on a

Anatomically, this is the shoulder region around thedaily base.

shoulder joint. The oriental medical term also refers toThus, psychosomatic problems develop when under

this region around the shoulder joint. Yet, in Japan the

stress. Actually, oriental medicine tends to detect theterm "shoulder stiffness" generally refers to a region

close correlation between mind and body. The sevencentering on the central fibers of the trapezius muscles

emotions: joy, anger, worry, anxiety, sadness, fear, andon top of the shoulders. The term "koru = become stiff,

frightsuffer stiffness", expressed by the character "凝る"may

becomecausative

factorsforthedevelopment of human diseases. They affect thefunctioning of both the internal organs as well as
physical functions and may lead to physical problems.
The reverse also holds true. That is the basis for theconcept of mind-body unity.
The term "stress" (stressed conditions) induced by avariety of stressors is often used in the sense of being
under "mental pressure". Yet, the original meaning of
this term is "distorted condition" and would be better

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usually meaning a stiffening and thus hardening of themuscles (sometimes also involving the skin andconnective tissue). Accordingly, shoulder stiffnessrefers mainly to symptoms of tensioning of the
trapezius muscles and their vicinity.
However, the patients who actually come fortreatment of shoulder stiffness complain about afeeling of distension, stiffness or tension over a region
extending from the neck to the shoulders, the

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

Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

andtimes; and the combination neck - nape once. The necksometimes the upper portions of the arms. In severe- shoulder is not found at all. Moreover, in the Ling

cases, symptoms may even be associated with

Shu the respective number of appearances of theseheadache, tinnitus, dizziness, and a general feeling ofcharacters is 54, 39, 1 and 1 time. In the Shang Han

fatigue or marked weariness, so that patients may

Lun the term nape - back appears 4 times, neck - nape

become unable to lead a normal daily life or work

seven times and head - nape six times. The term neckinterscapularregion,theanterior

chest,

Considering the above described scope, the muscles

seems to refer to the anterior neck, while nape means

included in the category of shoulder stiffness may beposterior neck. Further, the terms shoulder and nape

all the muscles of the neck, interscapular region,in expressions describing pathological conditions

scapular region, anterior chest, and upper arm. They

appears in the Sun Wen and Ling Shu in the form of

may give rise to pain or tension causing thediseases are located in the shoulders and back,development of a feeling of heaviness that will thenshoulder - back pain, internal pulling pain on shoulder

lead to the complaint of "shoulder stiffness".

and nape, shoulder - nape heat, interscapular pain,

Scrutinizing the classics reveals that the term

nape - shoulder pain, etc., while in the Shang Han Lun"shoulder stiffness" is not mentioned in the Su Wen or

terms like strong pain, strong tension, or simply strong

Ling Shu. Yet, in the section "Gyokuki Shinzo Ron",are found.

section No. 19 in the Su Wen, expressions like

In Japan during the Edo period, expressions close"internal pull on shoulder and neck" or "shoulder neckto the modern term shoulder stiffness, are found thatheat" are found that indicate symptoms involving thewere based on the etiologic factors cited in the Sunregion from the neck to the shoulders

Wen and Ling Shu. The book Shinkyu Choho Ki (1718,

Wind cold has been cited as a cause for thisby Masatoyo Hongo) cites: “When the shoulders hurt,

condition. This is derived form the latter half of ait may be due to phlegm, or else to cold wind, but often

famous passage stating, "Wind is the chief of many

indicates an stagnation of Qi and Blood and in

diseases." In the chapter on the channels in the Ling

acupuncture and moxibustion therapy for various

Shu, section 10 under "greater yang of the leg bladderdiseases, under the heading 'genpeki'.” Pain in thechannel ... in the primary disease of the channel, theshoulders certainly refers to shoulder stiffness and thedisease penetrates to the head and causes pain, it is as

relevant passage is followed by a detailed explanation

if the eyes would fall out, the nape might fall off andof the treatment for shoulder stiffness.

the back hurts. In this section, the phrase "like theIt should be noted in particular that phlegm andnape might fall off" could partially coincide with thewind cold are cited as causes for shoulder pain.

modern concept of shoulder stiffness. In the Shang

Moreover, the pathologic condition is considered to be a

Han Lu,in the section on differential diagnosis of pulse

stagnation of Qi and Blood. The term 'genpeki'

patterns for the greater yang diseases (section five), it

resembles aggregation-accumulation and is a generalsays: "In case of a greater yang disease the pulse willterm referring to either a mass in the hypochondrial or

float, there is stiffness and pain of head and neck andumbilical region or a lump in the chest and shoulder

chills.” The phrase seems to indicate the development

and nape stiffness (either of which are derived fromof shoulder stiffness during the early phase of a cold.

the Lexicon of Kampo Terminology), but here theIncidentally, in the Sun Wen, the character for

Choho Ki adopts only the latter meaning.

shoulder is found 37 times, the character for nape 38

Thus, 'kata-kori = shoulder stiffness' is not only atimes and the combination shoulder – nape threefeeling of tension and stiffness in the region around

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

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Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

the shoulder joint, but may also be a symptom

to be so, the depressive moods and fatigue etc. that

resulting from Qi and Blood stagnation caused by wind,Japanese people experience may still depend on thecold, dampness and phlegm. In this case thebackground formed by the characteristic Japanese

stagnation of Qi and Blood often results in thenatural environment, social structure, and humansimultaneous development of the entire body involving

relationships. These factors relate to the moods when

fatigue or suffering. Severe shoulder stiffness may

experiencing

thus lead to systemic problems.

feelings of fatigue accompanying the daily work or

muscletensioning

associated

with

about

study, so that for Japanese people the expression

shoulder stiffness there are in addition to the physicalkata-kori seems to be most suitable. The typicalsymptoms of shoulder stiffening, associated depressive

Japanese communication technique where a wordmoods, stress of human relationships, feelings of social

meaning physical fatigue should be used to express

entrapment, etc. that often serve as supplementary

mental problems is very intriguing.

Yet,

when

Japanese

peoplecomplainmeans of complaining about one’s personal condition
to others. For example, within social groups formed by

2. The condition of shoulder stiffness

companies, fatigue caused by human relationships

This refers to what the therapist can objectively

may be expressed as, "I have stiff shoulders”. In

feel (beginning with the muscles) and the pathologicalparticular, when people are keenly aware of other incondition of the patient's soft tissues. Classifying thesecases where the human relationship is not going well,findings into excess and deficiency, they would indicate

the expression "I get stiff shoulders whenever A isa state of excess. The patient may feel the condition ofaround," used by the affected people clearly, shows this.

stiffness himself, but s/he may also just feel someA representative expressions used for the complaining

localized pain or discomfort. Yet, if that feelingis, "I am tired" or "I have had enough." In addition tointensifies, it does not remain a localized subjective

that, the term "shoulder stiffness" is a skillful way offeeling of discomfort, but may develop into a feeling of

expressing the physical and mental fatigue notfatigue, loss of motivation or similar feelings ofrestricted only to the physical fatigue and is usually

discomfort affecting the entire body. The following

well understood in this sense by the listener.

table shows what patients and therapists feel fromIn this way various psychosomatic signs areinterlaced in a complex way and kata-kori, in its senseof both physical and mental fatigue, seems to be antheir respective point of view when faced withkata-kori (Table 1).

expression unique to the Japanese society that is not

Table 1

observed elsewhere abroad. However, the mental

Patient's

subjective

experiences

andtherapists

feeling of depression, interpersonal relations induced

objective findings in the presence of shoulder stiffness

stress and a feeling of social entrapment are also

(1) Subjective symptoms in patients with shoulder

known in other cultures outside Japan. They too will
most probably have some forms of expression that
correlate people's complaints of physical discomfort tothese psychological aspects. For example, in the final

stiffness
Local ..... pain, tenderness, feeling of distension,
heaviness, stiffness, fatigue, discomfort etc.
Systemic ..... generalized fatigue and discomfort,

analysis, the term headache may in American andfatigue,European societies possibly assume the meaning of

motivation, irritability, difficulties rising in thekata-kori = shoulder stiffness. Yet, even if this is said

weariness,

physicalheaviness,

lack

of

morning, depressive moods, hopelessness etc.
(2) Conditions the therapist can objectively identify in

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

Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

the presence of shoulder stiffness (classified into

(2)

excess and deficiency)

intervertebral discitis, periarthritis humeroscapularis

Excess.....

tension,swelling,

indurations,distension, hardness, etc.
lack elasticity, chilliness, getting moist etc.

shoulders include, as stated already above, not only
neck and shoulders, but may also extend over theentire back. The condition could affect a wide area,ofandcervicalsimilarsprains,
conditions,the cervical and thoracic vertebra as well as theneck, shoulders and chest may be either directly cause

The locations where patients complain about stiff

regionshoulder)orshoulder joint as the skeletal elements forming the

3. Sites of shoulder stiffnessa(frozenspondylosis

deformations, injuries, sprains, inflammation, etc. of

Deficiency ..... skin or connective tissue, muscles

including

Cervicaltheneck,thetrapezius,

semispinal, splenius, sternocleidomastoideus, scaleni,
levator scapulae muscles, in the scapular andinterscapular regions the supraspinatus, infraspinatus,
teres major, teres minor, latissimus dorsi, greaterrhomboid, lesser rhomboid muscles, the crector
muscles; or else in the anterior thoracic region the
pectoralis major, pectoralis minor, triceps brachii
muscles, etc. Figure 1 illustrates this. Moreover, in thetreatment of shoulder stiffness, general acupoints are
selected by palpating the affected region or specifictherapeutic acupoints that may include many local
points like GV20, BL10, GB20, GB21, TE15 etc.
Moreover, points on the arms include LI11, LI10, TE5,
LI4, HT3, LIV3, KI6, GB40. The acupoints lying
within the range indicated in the figure may
conceivably serve as therapeutic points, when they
have been identified as such through palpation in thepresence of relevant complaints.
4. Causes for shoulder stiffness

or conceivably lead secondarily to the development ofshoulder stiffness.
Yet, shoulder stiffness is not solely due to themusclesandskeletalelements

presenceofcomprisingtheshoulder locally.
(3)

In

the

headache,eyestrain,

astigmatism, dental caries, inflammation of thetemporomandibular joint, malocclusion, throat pain,
tinnitus, hardness of hearing and similar problems ofthe various organs of the head (in particular organs
related to the special senses) patients often complain
simultaneously also about shoulder stiffness. Whilethese causes undoubtedly may lead to shoulder
stiffness, the etiologic factors causing these conditions
may at the same time also induce shoulder stiffness
directly. Conversely, shoulder stiffness may also be acausative factor in the development of these symptoms
and possibly also modify the said symptoms.
(4) Shoulder stiffness caused by problems of thevarious internal organs. Patients with asthma or
cardiacdiseases,

digestive

organslikethegastrointestinal tract or liver, gynecologic or urologic
problems and the like affections of internal organs
may simultaneously cause one to complain about
shoulder stiffness.

What kind of factors cause shoulder stiffness?

(5) Anxiety, anger, stress and similar mental problems

The first cause that comes to mind is:can cause shoulder stiffness as well.

(1) Fatigue of the muscles forming the shoulder belt or(6) From a characteristically oriental medical point ofpoor posture, resulting in excessive or continuous

view wind, cold or damp evil and similar external

exertion of the muscles of the neck, shoulders andaffections, or else

arms that will lead to problems with the local muscles

phlegm are also conceivable.

of the shoulder.

7) The presence of chilling, hot flashes or dizziness,shoulder stiffness caused by

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

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Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

listlessness or heaviness of the legs, edema, insomnia

regions.

and similar indefinite complaints patients may

3. Examine the upper and lower extremities for

simultaneously lead patients to complain of shoulder

swelling and tender spots with reference to thestiffness. An imbalance of the autonomic nervous

channels.

system considered to be a causative factor for

Check through palpation of the shoulder region, its

indefinite complaints, has also been suggested as a

vicinity and more distant areas with reference to thepossible cause for shoulder stiffness.

course of the channels and the muscles along thechannels and the nervous system for sites showing

II. Approach to the determination of therapeutic
points for shoulder stiffness
1. Identification of painful or stiff regions
For the treatment of shoulder stiffness it is first of
all necessary to identify the painful or stiff regions.
These may be found by: (1) instructing the patient toflex the neck anteriorly, posteriorly or laterally, rotate
it or flex it obliquely, assume a position of the limp(s)that usually induces the pain or stiffness in order toclearly identify the painful or stiff regions; (2) when
there is pain or stiffness of the muscles, it is necessary

signs of deficiency or excess. The most distant regions
are the upper and lower extremities.
4. Palpate the abdomen, lumbar and sacral vertebrae
for tension and tenderness.
Due to the correlation with the autonomic nervous
system and the inner organs’ reactive sites of theabdomen, lumbar and sacral vertebrae may be related
to shoulder stiffness and thus serve as sites fortherapeutic stimulation. Palpate these regions andcheck for relevant reactions.

to identify the involved muscle(s). Clearly define,III. Basic concepts of acupuncture, moxibustion

which of the above mentioned muscles of the neck,and massage treatment

shoulder, chest, and arm are involved. Pain, swelling

1. Most basic concepts during the identification ofor tenderness may also be observed in other tissues

pathologic musculoskeletal conditions to be treated:than the muscles; and (3) for example tendons,(1) Is it solely a problem of the locomotor system?

ligaments, connective tissue, skin etc., in which case the(2) Should an involvement of various organs, distantrespective painful or stiff regions need to be identified.

organs and tissues be considered?

Among these (2) and (3) are achieved through palpation,(3) Is the condition due to extrinsic pathogenic factors?

but in particular, (3) requires very careful palpation in(4) Is there a strong influence of mental, psychologic

order to identify the affected regions.

problems?
The treatment will differ depending on these

2. Search for sites of swelling or pain in the local area(above, below, left, right, anterior, posterior).
Once the site of the complaint has been clearly
identified, its vicinity has to be palpated for swellingand pain. Again, not only swelling and pain, but also
indurations or indentations, and areas of decreased
sensitivity are checked. This is required in order to
identify the areas to be treated.
Figure 1 shows that the head, neck, interscapularregion and anterior chest are conceivable adjacent52

considerations.
2. Establishing the therapy(1) Treatment of local pain or stiffness
Perform an anamnesis of local pain or stiffness, or
ask the patient to assume the painful posture to
identify the relevant regions and then treat the
involved sites directly.
A major portion of the current acupuncture andmoxibustion treatment is directed locally at the

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

Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

shoulder stiffness and needling of the tensioned
muscles. In the book Shinkyu Chouho Ki of the Edo
period, the following passage is found.

(2) Treatment of related but not local sites(therapies exploiting the somato-visceral reflex,
back shu and anterior mu points)"First, massage and twist the shoulder with the

When pain in muscles, and the like connective

hands, stroking downwards and open the flow of Qitissues or referred pain, has been induced via thebefore needling. Deep needling may be a mistake. In

somato-visceral reflex, the site of the pain is treatedother words, indiscriminate needling may injure thelocally, but at the same time, the organs and other

patient. For the needling the needles should be retained

causative factors of the condition are also treated.

between skin and muscles. At least, the muscles should(3) Treatment of distant sites

not be needled. Do not use needle twirling on theTreatment follows the pathologic condition.

shoulders and back. Stone needles should be used. Use

Treatment according to disease patterna needling tube and flick the needle in, so that it drains* Performed referring to the course of nerves, channels,

Qi and Blood. This will have a quick effect. Also, thethe muscles along the channels, special effect points,

tube should be thrust. This will inevitably lead toclinical experience etc.

bleeding and thus eliminate the pathogenic Qi. In* Selection of points based on the identification of theancient times they used the tip of stones to pierce sites

oriental medical disease pattern, performance ofof pain or numbness, disrupt the channels, eliminate

tonification and sedation.

the evil influences, and thus the acupuncture classics* In general clinical practice, the filiform needle andstated the use of stone needles to drain pus and blood."

manual stimulation are used.

(cited from the Shinkyu Chouho Ki).

* Intradermal or press-needles are often used, if after

The intent is not to pierce the muscles, but rather

the above described treatment pain remains, in order

insert the needles shallowly, or else perform blood

to prolong the therapeutic effects.

letting for cases, as described above where wind evil has* Network vessel pricking is also effective, but ininvaded Qi and Blood and thus led to their stagnation.

Japan it is not generally used.

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

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