ACUPUNCTURE FOR THE TREATMENT OF

SHOULDER PAIN:
AN EVIDENCE-BASED ASSESSMENT

Prepared March 2012

Society for Acupuncture Research

Acupuncture for the Treatment of Shoulder Pain

Table of contents
PREFACE...1
PROPOSED MECHANISMS.1
METHODOLOGICAL CONCERNS..2
SHOULDER PAIN
Introduction.....................5
Epidemiology..................6
TEAM View of Shoulder Pain...........................8
Search Methods...............9
Systematic Reviews........10
Randomized Controlled Trials.....11
Commentary...15
Conclusions.16
Acknowledgements...17
Conflicts of Interest17
References18
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PREFACE
The Evidence-Based Assessment Summaries project provides a comprehensive
evaluation of the literature, with a focus on systematic reviews and randomized
controlled trials (RCTs). These two prominent forms of evidence are often placed at the
pinnacle of an evidence-based hierarchy. Considerations of the strengths and weakness
of this hierarchical approach are beyond the scope of this project, yet it is worth noting
that this concept has led to substantive discussions and alternative evidence models.1
Our aim is to evaluate the literature including, when appropriate, other levels of
evidence, e.g. non-randomized controlled trials, outcomes research, and case reports.
Commentary is provided on the evidence included in this review to offer a perspective
representative of the board of the Society for Acupuncture Research (SAR). The
overarching goal of these Evidence-Based Assessment Summaries is to inform
stakeholders of trends in the acupuncture literature and to provide unique and expert
commentary on the state of this evidence. A review of this nature is remiss without
discussion of the proposed mechanisms of action (of acupuncture) and methodological
concerns in the literature, both of which are included at the beginning of each EvidenceBased Assessment Summary.

PROPOSED MECHANISMS
Acupuncture is the most frequently utilized modality within Traditional Chinese
Medicine (TCM) and although mechanisms of action remain poorly understood,
numerous experimental models have been studied. Two main areas under investigation
relate to the nervous system and connective tissue. A range of reproducible effects on
the peripheral, central, and autonomic nervous systems have been demonstrated in
humans and animals correlating to reductions in pain and inflammation, as well as
regulation of endocrine function.2-5 Human neuroimaging studies have suggested that
chronic pain reduction by acupuncture is accompanied by significant neuroplasticity in
the brain.2,6 Experiments in animal models demonstrate potential frequency-related
effects for electroacupuncture, where combined high (100 Hz) and low (2 Hz) frequency
stimulation may release a full spectrum of endogenous opioidergic neuropeptides:
enkephalin, -endorphin, dynorphin and endomorphin.7-9 These endogenous opioids
released within the central nervous system are proposed to mediate the analgesic effects
of acupuncture.7 For instance, human neuroimaging with positron emission
tomography (PET) with contrast agents specific for opioid receptor binding has
demonstrated that acupuncture can increase mu-opioid receptor binding potential in
chronic pain patients.8
A more recent focus of investigation on the physiological basis of acupuncture is the
connective tissue system. It has been proposed that acupuncture points (acupoints) and

meridians occur at locations where connective tissue planes merge.9 Current models
suggest that stretching of the connective tissue takes place during acupuncture
needling, which results in active fibroblast-induced cytoskeletal remodeling.10-13
Although these responses may lead to physiologically relevant effects, their
relationships to clinical outcomes remain unknown.10,14,15
It is important to note that the nervous system and connective tissue models may not be
mutually exclusive and may in fact be synergistic. As succinctly stated by Dr. Helene
Langevin in summarizing findings from the 2007 Society for Acupuncture Research
conference: Iterative testing, expanding, and perhaps merging of models will potentially lead
to an understanding of the effects of...acupuncture...that is solidly rooted in physiology.16

METHODOLOGICAL CONCERNS
This section summarizes current issues regarding the design, reporting, and assessment
of acupuncture research. For a more in-depth discussion of these issues, please refer to
the White Paper from the Society for Acupuncture Research, Paradoxes in
Acupuncture Research: Strategies for Moving Forward.17
Design Concerns: Sham Controls
The above-cited White Paper states ...[although] well-designed clinical trials have reported
that true acupuncture is superior to usual care, it does not significantly outperform sham
acupuncture.... Within these trials a number of factors, most of which remain poorly
understood, could contribute to Type II errors (i.e., false negatives). Of primary concern
is the use of acupuncture sham controls that have been demonstrated to be active, not
inert.18
Invasive vs. Non Invasive
Sham control procedures can be divided into two main categories: invasive and noninvasive. Invasive techniques involve the insertion of acupuncture needles at either
acupoints, non-relevant acupoints, or locations not known to be primary acupoints.
Insertion depths are generally categorized (in relation to the verum treatment) as
superficial or equivalent. Superficial insertions (1-2 mm) at non-acupoint locations were
initially posited to be an inert treatment as compared to standard needling depths at
verum acupoint locations. These notions are not consistently supported by numerous
recent trials that have shown sham needling and verum needling to be equally
effective.18-20 Such trials may inadvertently mimic classical Japanese acupuncture styles
that needle at minimal insertion depths, often at the location of tender points (meridian
or non-meridian) for optimal treatment effects.21,22

Several non-invasive sham techniques exist, the most common of which are 1) a
placebo needle whose blunted tip retracts within the needle shaft when in contact with
the skin, or 2) pressing of the skin with a blunt device (e.g. empty guidetube or
toothpick). Non-invasive procedures were designed to provide a true inert control on
the assumption that penetration of the skin is a requirement for providing a therapeutic
stimulation of the acupoints. This assumption is at odds with classical acupuncture texts
where the use of non-insertive techniques is clinically indicated in numerous instances,
some of which are still in popular practice and comprise the primary type of needling
technique, e.g. Shonishin or Toyohari. Furthermore, empirical evidence has
demonstrated significant benefits in clinical trials utilizing this type of non-insertive
control.23 These findings may be explained by preliminary data regarding the cascade of
physiological effects related to C-tactile fibers, that can be initiated by physical pressure
of the skin alone24,25
In summary, numerous clinical trials have failed to detect significant clinical or
statistical differences between sham controls (invasive or non-invasive) and the
acupuncture intervention. When assessing studies that evaluate the efficacy of
acupuncture compared to a sham control, it is important to keep in mind that most
studies have used sham controls that are not truly inert. Until both needling and nonneedling components of acupuncture are better defined and experimentally evaluated,
independently and in combination, it remains challenging to appropriately design sham
controls that exclude the active components of an acupuncture treatment. In the
meantime, scientists interested in addressing questions regarding the efficacy of
acupuncture (designs with sham controls) should, ...clearly state the hypothesis that is
being tested and select a control procedure(s) that will most specifically test this hypothesis.17
Reporting Concerns: Randomized Controlled Trials and Systematic Reviews
Randomized controlled trials (RCTs) and systematic reviews are often regarded as the
pinnacle of the evidence-based pyramid. Although not without controversy, this
practice is commonly employed in an evidence-based assessment of the literature.26,27
Relying solely on RCTs and systematic reviews to inform conclusions from the
acupuncture literature poses challenges for numerous reasons. Two such instances are
the relative paucity of methodologically sound, large-scale trials28-30 and the dearth of
trial replication. This deficit is further highlighted when low-quality trials are included
in systematic reviews and meta-analyses.31,32
Current guidelines for the development and reporting of systematic reviews are
outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement.32 This document succinctly states: The likelihood that the treatment
effect reported in a systematic review approximates the truth depends on the validity of the

included studies. Despite the quality and acceptance of the PRISMA statement, two
primary concerns are apparent when applied to acupuncture RCTs. First, there are no
guidelines to inform the adequacy of the [acupuncture] treatment protocol. Second,
although details of the study selection process are required (item 9 of PRISMA), this
document fails to address the imperative of assessing the trial quality for exclusionary
purposes.33 These issues in reporting of systematic reviews may introduce bias if poorly
designed or methodologically flawed trials are included for analysis.34 An opinion piece
and re-analysis of a systematic review of acupuncture for neck pain35 highlights this
notion.36 The authors suggest that it is inappropriate for systematic reviews to draw
conclusions from numerous low quality RCTs. In the re-analysis of the original review
by White & Ernst35, White31 suggests that if appropriate inclusion criteria were utilized,
3 rather than 14 RCTs would have been included, too few trials to draw definitive
conclusions. The consistent of use STRICTA guidelines, recently revised and now
situated within the CONSORT family of reporting guidelines will help improve the
quality of reporting of the acupuncture used in clinical trials over time.37
Assessment Concerns: Semantics and Errors of Scale
The term acupuncture can be confusing, as it can infer a unique meaning dependent
upon the context or audience.17 As an example, it may refer to a procedure of inserting
an acupuncture needle, as in a scientist inserted an acupuncture needle into a single
acupoint on a rat. In contrast, it may refer to a complex intervention that consists of a
unique diagnostic process to arrive at a treatment plan. This plan, administered by a
practitioner, may consist of the modality acupuncture (use of a diagnostic process to
determine point locations for the insertion of acupuncture needles), with adjunct
modalities often incorporated, e.g. massage, herbs, and cupping. To ameliorate this
confusion SAR has proposed the acceptance of precise acupuncture-related definitions
(i.e. the definitions for acupuncture treatment is different than for acupuncture
needling).
Adding to the issue of semantics is the concept of scale. Borrowing from
anthropological terminology, an error of scale refers to inappropriately inferring
correlations between distinctly different groups, a concept that may occur in the
acupuncture literature (see Table 1). Sweeping conclusions regarding the totality of
acupuncture effectiveness are no more appropriate than stating pharmaceuticals are or are
not effective for a given condition. Within the pharmaceutical example, statements
regarding a specific dosage (e.g. 10 mg for 3-months), of a pharmaceutical (Lipitor) are
appropriate when investigating effectiveness for a given condition
(hypercholesterolemia). As such, the modality of acupuncture is not under evaluation,
rather a specific style of acupuncture (e.g. Chinese style using electroacupuncture), with

a specific treatment protocol (a fixed-set of acupoints and treatments) that is part of a

larger and specific system of care (Traditional Chinese Medicine).
Table 1. Comparisons of Scale in Systems of Healthcare
System
Biomedicine
Traditional Chinese Medicine
Modality
Treatment Style

Protocol

Pharmacology

Acupuncture

Drug class
-Statins
-Individual drug

Chinese acupuncture style

-Electroacupuncture
-Acupoint protocol

Dosage, frequency,
duration of
treatment

Dosage, frequency, duration of

treatment
Acupuncture needle manipulation
-Angle, depth, stimulation
technique, retention time

To further highlight this concept, consider the following conclusion from a recent
systematic review: The evidence is not convincing to suggest acupuncture is an effective
treatment for hot flush in patients with prostate cancer.38 Here the authors use the term
acupuncture, to infer generalizations for the modality of acupuncture, yet the review
includes 6 trials (1 RCT and 5 outcomes trials) with varying acupoint protocols. Of the
trials, five employed classical acupuncture (using electroacupuncture n=3; or manual
acupuncture n=2) and one utilized auricular acupuncture (NADA protocol). When
varying treatment protocols are utilized it is inappropriate to consider tallying results,
as a negative trial does not negate a positive one. The conclusion by Lee et al is
commonplace and exemplifies the breadth of the error of scale issue in the acupuncture
literature. It is imperative to emphasize that a lack of evidence does not mean a lack of
effectiveness, as succinctly stated by the Research Director at the American Physical
Therapy Association.39 In consideration of this caveat, we utilize the term acupuncture to
describe the protocol within the context of each particular trial, not as an assessment of
the modality or system in general.

SHOULDER PAIN INTRODUCTION

Shoulder pain typically refers to disorders of the articular surfaces of the shoulder
girdle, including the glenohumeral, acromioclavicular, and sternoclavicular joints.40 The
most common diagnoses of shoulder pain relate to rotator cuff dysfunction (including
impingement syndrome), adhesive capsulitis, glenohumeral osteoarthritis, and
subluxations (including dislocations).41 The majority of acupuncture research has been

conducted on two broadly categorized shoulder pain disorders: chronic shoulder pain
and rotator cuff disorders. Chronic shoulder pain is categorized as pain lasting longer
than six months. The insinuating pain may be the result of any of the common shoulder
pain diagnoses, e.g. an untreated rotator cuff tear. This Evidence-Based Assessment
summary will focus on the treatment of chronic shoulder pain and rotator cuff
disorders.

EPIDEMIOLOGY
Pathology
The diagnosis of common shoulder disorders relies on three key areas: patient history,
physical exam, and diagnostic imaging.42 When confirming a diagnosis, consideration
of patient characteristics can be of assistance, for example age at onset of pain. In
patients <40 years, glenohumeral instability or mild rotator cuff disorders are likely
etiologies. In patients >40 years, by contrast, clinicians should suspect glenohumeral
osteoarthritis or more severe/chronic rotator cuff disorders. Another clinical variable is
co-morbidities: adhesive capsulitis (frozen shoulder) may be associated with diabetes
and thyroid disorders. Additional factors, such as recreational status, location of pain
and response to treatments are also of diagnostic use.
Recent trials and reviews advise limited use of imaging technology, suggesting detailed
patient history and orthopedic testing is sufficient for accurate diagnosis.43-45 The use of
imaging techniques (Ultrasound or MRI) is primarily recommended for accurate
differentiation of traumatic events (dislocation) or discrimination between full vs.
partial-thickness rotator cuff tears.
Etiology
The etiology of common shoulder pain disorders is primarily grouped into four
categories: 1) Tendon inflammation or tears; 2) Joint instability; 3) Arthritis; and 4)
Fracture.46 Other red flag etiologies, which require immediate referral, include tumor,
infection, and nerve-related disorders. Specific shoulder disorders, such as adhesive
capsulitis, may have unique and or/complex etiologies related to diabetes. Chronic
shoulder pain (>6 months) is often a result of unsuccessful treatment for a specific
shoulder disorder.41 Most commonly, chronic shoulder pain is related to rotator cuff
tears, impingement syndrome, tendonitis, adhesive capsulitis, and/or glenohumeral
osteoarthritis.
Incidence
Shoulder disorders are associated with substantial disability on tasks essential to daily
living (e.g. dressing and work) and are prevalent in 7-36% of the general population.47-49

Data indicate that shoulder pain is the third most common musculoskeletal condition
(following back and neck pain).48 Of the common shoulder pain conditions, rotator cuff
disorders are most prevalent, accounting for 10%, followed by adhesive capsulitis (6%)
and glenohumeral osteoarthritis (2%); the majority of shoulder pain disorders are
poorly diagnosed.41 Estimates suggest that 40-50% of patients with a specific shoulder
pain disorder will develop chronic shoulder pain.47,50,51
As a whole, shoulder pain disorders often lead to impaired sleep, mood, and
concentration.52 Evidence suggests that individuals with shoulder pain report
substantially lower than normal values on quality of life questionnaires (e.g. SF-36),
especially in categories associated with physical and emotional function. Evaluation of
patients perception of their general health reveals that shoulder pain disorders lead to
quality of life impairment on par with several major medical conditions, e.g. heart
disease, diabetes mellitus, and clinical depression.52
Economics
Estimates of the economic impact of shoulder pain are scarce and interpretation of
current data poses challenges, primarily due to inconsistent diagnostic parameters. An
evaluation of U.S. data from 2000 estimates the annual direct costs for the treatment of
shoulder dysfunction at $7 billion.41 Data from Norway indicate that physiotherapy
treatments account for 60% of the observed direct costs with a relatively low overall cost
(direct and indirect) of 4,139 (~$5,400) per patient.53 The majority of costs (up to 80%)
are attributable to the indirect costs related to sick leave.50,53 Overall, evidence indicates
that treatment costs are elevated by a small proportion of patients with recalcitrant
shoulder pain; estimates suggest that 12-20% of patients account for up to 90% of the
total costs.
Allopathic Treatment Strategy
The main conclusion from recent investigations is that health care interventions should
focus on getting patients back to work, with special attention towards the small group
that generates the highest costs.53 To achieve this goal, treatment should focus on
improved function through pain relief and enhanced mobility.45,54,55 Conservative
treatment for common shoulder disorders includes: NSAIDs, corticosteroid injections,
and physiotherapy.55,56 Current evidence on the benefit of these therapies is limited due
to differing definitions of shoulder pain, heterogeneity of interventions, poor
methodological quality, and small sample sizes.57
Estimates indicate that up to 50% of patients with shoulder disorders develop chronic
shoulder pain. Often, these patients are recalcitrant to conservative therapeutic options
and more aggressive treatment options are sought. Hyaluronate injection is a novel

treatment for patients with shoulder pain. A recent meta-analysis (19 RCTs; 2,120
participants) suggests that injection of hyaluronate can improve pain and function in
patients with chronic shoulder conditions.56 In comparison to corticosteroid injection,
hyaluronate injection was modestly more effective with no increases in adverse events.
Surgical interventions, such as arthroscopic acromioplasty, are suggested if conservative
treatment options fail. The use of arthroscopic procedures appears to be on the rise; an
analysis of data from New York State reveals a four-fold increase from 1996-2006.58
Despite the increase in these procedures, publications suggest no difference between the
effects of physical therapy and surgical interventions.59-62 A recent cost-of-illness study
from Norway supports the use of surgical interventions for specific cases, but
concludes: ...the increase in shoulder surgery cannot be explained by the practice of evidencebased medicine.53

TRADITIONAL EAST ASIAN MEDICINE VIEW OF SHOULDER PAIN

Traditional East Asian Medicine (TEAM) is a prominent system of healthcare, with
trends of increasing use in the United States. Recent national (U.S.) data indicates a
rapid growth of TEAM over the past decade with a 40% increase in LAcs and a greater
than three-fold increase in patient visits to acupuncture practitioners (5.4 to 17.6
million).63 Individuals suffering from shoulder pain and other joint-related disorders
frequently seek treatment options from providers of complementary and alternative
medicine (CAM).64 Of the numerous CAM modalities, the use of acupuncture is on the
rise and approximately 16% of acupuncture visits in the U.S. are for the treatment of
joint related pain.65
Acupuncture is an integral modality of TEAM, a complete system of healthcare, which
includes additional therapies such as herbal medicine, moxibustion, and massage. The
term "acupuncture" describes a family of procedures involving the stimulation of
anatomical points on the body using a variety of techniques. The acupuncture technique
that has been most often studied scientifically involves penetrating the skin with thin,
solid, metallic (filiform) needles that are manipulated manually or by electrical
stimulation.
From the perspective of TEAM, shoulder pain involves three primary channels (or
meridians): the Large Intestine, Small Intestine, and San Jiao (triple burner). Each of
these meridians courses the local area of the most common shoulder pain disorders.
Combined with a blockage of Qi and/or blood in these channels, patients may present
with additional etiological factors, each with unique pattern diagnoses: 1) external
pathogens (e.g. wind-damp-cold), 2) internal disharmony (e.g. liver Qi disharmony), or

3) lifestyle imbalances (e.g. kidney Qi deficiency).66-68 To understand these concepts it is

imperative to understand pattern differentiation, a theoretical construct that defines the
TEAM system of healthcare. In essence, this means for each medical condition (such as
shoulder pain) practitioners are trained to determine what pattern patients present
with. Based on this pattern (e.g. blockage of Qi, or a deficiency of kidney Qi),
individualized treatments are designed to maximize benefit.
In TEAM, pain in general is considered to be an obstruction of qi and blood, which in
turn may be due to an underlying internal disharmony or imbalance of the organ Qi
(e.g. kidney Qi deficiency). A famous Chinese axiom expresses the essential nature of
pain: Where there is free flow [of Qi] there is no pain, where there is pain there is no free flow.
Shoulder pain, as a symptom, indicates a stagnation of the movement of qi and blood.
The specific pattern differentiation of these imbalances is based on the nature and
location of the pain and other secondary symptoms (e.g. bowel movements, digestion,
and sleep). These symptoms gain clinical significance in the context of patients signs,
mainly the quality of pulses at the radial artery, the characteristics of the tongue, and
general observations of the patients demeanor.69

SEARCH METHODS
The following databases were queried to locate systematic reviews and clinical trials of
acupuncture for the treatment of shoulder pain:
Medline; February 2012
MeSH Search Terms: (Acupuncture Therapy OR Electroacupuncture) AND
Shoulder Pain: (n=143)
Limits: Humans, Reviews (n=16)
Limits: Humans, Clinical Trial (n=56)
CINAHL via EbscoHost; Februrary 2012
Search Terms: (Acupuncture OR Electroacupuncture) AND Shoulder Pain:
(n=82)
Limits: Humans, Systematic Reviews (n=6)
Limits: Humans, Clinical Trial (n=14)
Alt-Health Watch and AMED via EbscoHost; Februrary 2012
Search Terms: (Acupuncture OR Electroacupuncture) AND Shoulder Pain:
(n=65)
Limits: Peer Review Journals (n=17)

 AcuTrials*; February 2012

Search Term: Shoulder Pain (n=29)
*AcuTrials is a database of randomized controlled trials and systematic reviews of acupuncture developed by the
Oregon College of Oriental Medicine; www.AcuTrials.ocom.edu

SYSTEMATIC REVIEWS
A single systematic review has been conducted on the treatment of shoulder pain with
acupuncture.70 To provide context for the treatment options of shoulder pain, systematic
reviews of usual care strategies are highlighted in Table 2, in addition to the review of
acupuncture.
Table 2. Select Systematic Reviews for Shoulder Pain
1. Green S, Buchbinder R, & Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev.
2005;(2):CD005319.
- Number of trials: n=9 (525 participants)
- Modalities included: Acupuncture and electroacupuncture
- Conclusion: There is little evidence to support or refute the use of acupuncture for shoulder pain
although there may be short-term benefit with respect to pain and function.
2. *Saito S, Furuya T, & Kotake S. Therapeutic effects of hyaluronate injections in patients with chronic
painful shoulder: a meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken).
2010;62(7):1009-18.
- Number of trials: n=19 (2,120 participants)
- Modalities included: injection of hyaluronate
- Conclusion: Hyaluronate injections are a valuable alternative to other conservative methods for
the treatment of chronic painful shoulder...relatively small number of studies
included...emphasizes the need for additional investigations
3. *Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database
Syst Rev. 2003;(2):CD004258.
- Number of trials: n=26 (varied per modality: median 48 participants per trial; range 14-180)
- Modalities included: Exercise, ultrasound, laser therapy, mobilisation, corticosteroid injections
- Conclusion: The small sample sizes, variable methodological quality and heterogeneity in terms of
population studied, physiotherapy intervention employed and length of follow up of RCTs of
physiotherapy interventions results in little overall evidence to guide treatment.
*Not Acupuncture Related; Allopathic Treatment Reviews

The Cochrane Collaboration review on acupuncture identified nine trials of shoulder

pain due to varying etiologies: rotator cuff syndrome, periarthritis, adhesive capsulitis
(frozen shoulder), and mixed-type shoulder pain.70 Two trials on rotator-cuff disorders
assessed short-term success (post intervention) and a meta-analysis of data demonstrate
inconclusive findings as compared to sham acupuncture. The remainder of trials were
heterogeneous, disallowing additional meta-analyses. Diverse etiologies, small sample
sizes, and varying degrees of methodological quality in the trials precluded definitive
conclusions. Despite these limitations, the authors suggest, ...acupuncture may provide
immediate short-term improvements in both pain and function for shoulder disorders.

10

RANDOMIZED CONTROLLED TRIALS

Numerous clinical trials on the effects of acupuncture for shoulder pain have been
published since the 2005 Cochrane review.70 These recent trials can be broadly grouped
in two categories: chronic shoulder pain and rotator cuff disorders. Six RCTs focus on
chronic shoulder pain, primarily rotator cuff induced, but also due to osteoarthritis and
adhesive capsulitis.71-76 Five trials focus on rotator cuff disorders, including: rotator cuff
tendonosis (tendinitis), impingement syndrome, and post-operative functional
improvement from arthroscopic acromioplasty.77-81 This summary will focus on trials
with >40 participants; four RCTs did not meet this criteria.72,75,76,80 A selection of key
trials are highlighted in Table 3; trials are summarized below by category (chronic
shoulder pain & rotator cuff disorders).
Chronic Shoulder Pain Disorders
The most recent trial to date on chronic shoulder pain is a multi-center trial (31 clinics)
from Germany.71 Participants (n=424) with uni-lateral shoulder pain (6-24 months;
excluding osteoarthritis) were randomized to one of three groups: 1) Acupuncture; 2)
Sham acupuncture; or, 3) Usual care. At the treating physicians discretion, up to 15
semi-individualized acupuncture treatments were administered over six weeks (1-3
sessions/week). Sham acupuncture was administered at non-acupoints with the same
number and frequency of treatments. The usual care group received medication for
daily use (diclofenac, 50 mg) and up to 15 physiotherapy-related treatment sessions.
Analysis of the primary endpoint (50% reduction in pain (VAS) at 3-month follow-up)
revealed that acupuncture was statistically and clinically superior to both sham and
usual care (p<0.01). The responder rates per group were:
Acupuncture: 65% (95% CI 56 74%)
Usual care: 37% (95% CI 2450%)
Sham acupuncture: 24% (95% CI 939%)
The authors concluded: ...acupuncture more effectively reduces pain and improves mobility
in patients with chronic shoulder pain than does standard therapy using NSAIDs and
physiotherapy. The therapeutic effect [lasts]...up to 3 months, with the difference between
acupuncture and standard therapy increasing over time.
A large multi-center trial from Spain (6 clinics) assessed the benefit of acupuncture
treatment adjunctive to physiotherapy for the treatment of chronic shoulder pain
(rotator cuff tendonitis, bursitis, and adhesive capsulitis).73 Participants (n=425) were
randomized to two groups: Acupuncture plus physiotherapy or sham-TENS plus
physiotherapy. Both groups received 15 physiotherapy sessions (5/week) over three
weeks. Participants in the acupuncture group were administered three treatments (1/
week) to a single acupoint (ST-38). After needle insertion and obtaining deqi (needle

11

stimulation technique) participants were instructed to move their shoulder through

abduction, internal, and external rotation. In the control group, which received mockTENS (deactivated device) applied to the leg, no shoulder movements were required.
The primary endpoint (ConstantMurley Score at week four) demonstrated a significant
effect for the acupuncture group (SMD 6.0 points [95% CI 3.2 - 8.8]; p<0.001). Secondary
assessments revealed that 53% of the patients in the acupuncture group decreased
medication use, compared to 30% in mock-TENS (p<0.001). Significant positive changes
in the subjective assessments of the C-M Score were maintained at 6 & 12-month followups (objective measures were not collected). The authors concluded: single-point
acupuncture associated with physiotherapy improves function and alleviates pain in the shoulder
to a greater degree than does physiotherapy as the sole treatment...As this technique is simple
and safe, it is recommendable as an auxiliary treatment for subacromial pathologies.
A trial from Spain compared the effect of electroacupuncture to non-invasive sham
acupuncture for chronic shoulder pain.74 Participants (n=130) with diagnosed bursitis,
tendonitis, or adhesive capsulitis received eight standardized weekly treatments at four
acupoints. These acupoints were reported to be effective in an earlier pilot trial.82
Acupuncture was found to be more effective than sham treatment for the primary
endpoint (VAS, pain intensity) at 6-month follow-up (2.0 difference [95% CI 1.22.9];
p<0.001). All secondary outcomes (e.g. ROM, functional ability, NSAIDS intake)
demonstrated significantly better effects for the acupuncture group; effects were
maintained at the 6-month follow-up. The authors concluded: Acupuncture is an
effective long-term treatment for patients with shoulder pain (from soft tissues lesions) in a
primary care setting.
Rotator-Cuff Disorders: Impingement Syndrome
The most recent trial, from Sweden, compared the effects of two standardized
interventions for patients (n=123) with subacromial impingement syndrome:
acupuncture plus exercise vs. corticosteroid injection.77 Ten acupuncture treatments
were administered (2/wk) over five weeks at a standardized set of acupoints. In
addition, home-based exercise was performed daily. For the corticosteroid group, a
subacromial injection was performed; if deemed unsuccessful, a second injection was
administered. At the end of treatment, both groups demonstrated clinically and
statistically (p<0.001) significant improvements in pain and function (primary
endpoint; assessed via: AdolfssonLysholm score). These effects were maintained at the
3, 6 and 12- month follow-up periods. No significant differences were observed between
groups. The authors concluded: ...both treatments can be recommended for patients with
subacromial impingement syndrome...the choice could be influenced by the accessibility of the
treatment and the individual patients preference.

12

Table 3. Selected RCTs of Acupuncture for Shoulder Pain

1. Johansson K, Bergstrm A, Schrder K, et al. Subacromial corticosteroid injection or acupuncture with
home exercises when treating patients with subacromial impingement in primary care--a randomized
clinical trial. Fam Pract. 2011;28(4):355-65.
- Trial size: n=123
- Interventions: 2 Groups: Acupuncture + exercise (2/wk for 5wks; daily exercise) vs. corticosteroid
injection (up to 2 injections)
- Conclusion: Both subacromial corticosteroid injection and a series of acupuncture treatments
combined with home exercises significantly decreased pain and improved shoulder function...
neither treatment was significantly superior to the other.
2. Molsberger AF, Schneider T, Gotthardt H, & Drabik A. German Randomized Acupuncture Trial for
chronic shoulder pain (GRASP) - a pragmatic, controlled, patient-blinded, multi-centre trial in an
outpatient care environment. Pain. 2010;151(1):146-54.
- Trial size: n=424
- Interventions: 3 Groups: Chinese acupuncture (1-3 Txs/wk for 6wks; 15 total); sham acupuncture;
or conventional orthopedic treatment (medication + 15 PT sessions)
- Conclusion: ...acupuncture treatments...are more effective than conventional standard therapy
with NSAIDs and physiotherapy. After the end of treatment, the therapeutic effect of
acupuncture lasts for 3 months.
3. Vas J, Ortega C, Olmo V, et al. Single-point acupuncture and physiotherapy for the treatment of painful
shoulder: a multicentre randomized controlled trial. Rheumatology (Oxford). 2008;47(6):887-93.
- Trial size: n=425
- Interventions: 2 Groups: Acupuncture + physiotherapy vs. Sham-TENS + physiotherapy (1
acupuncture session/wk to ST-38; 15 physiotherapy sessions over 3wks)
- Conclusion: Single-point acupuncture in association with physiotherapy improves shoulder
function and alleviates pain, compared with physiotherapy as the sole treatment. This
improvement is accompanied by a reduction in the consumption of analgesic medicaments.
4. Guerra de Hoyos JA, Andrs Martn Mdel C, Bassas y Baena de Leon E, et al. Randomised trial of
long term effect of acupuncture for shoulder pain. Pain. 2004;112(3):289-98.
- Trial size: n=130
- Interventions: 2 Groups: Electroacupunture + diclofenac vs. sham acupuncture + diclofenac (8
weekly sessions; medication as needed)
- Conclusion: All results consistently suggested that acupuncture is...effective to treat pain and
disability in patients with shoulder pain from different causes, mainly rotator cuff disease and
capsulitis.
5. Gilbertson B, Wenner K, & Russell LC. Acupuncture and arthroscopic acromioplasty. J Orthop Res.
2003;21(4):752-8.
- Trial size: n=40
- Interventions: 2 Groups: Acupuncture vs. sham acupuncture (3/wk for 4wks; 12 total)
- Conclusion: Following arthroscopic acromioplasty for impingement syndrome...acupuncture
treatments exhibited significantly greater improvement than...sham in the following categories:
(1) overall recovery as measured by the UCLA shoulder scale; (2) lower pain levels; (3) less
analgesic use; (4) improved range of motion; and (5) better patient satisfaction.

In an earlier trial, the same group of Swedish researchers randomized participants (n=
85) to acupuncture or ultrasound therapy for the treatment of shoulder impingement
syndrome.79 Both groups received 10 sessions, (2/wk) for five weeks, and also received
instruction for daily home exercises. A standardized acupuncture protocol was
administered by physical therapists trained to locate four acupoints. Seventeen
participants (acupuncture n=9, ultrasound n=8) who deviated from the treatment
protocol (they received additional therapy) were included in the intention to treat

13

analysis (ITT). This analysis demonstrated no between-group differences at any followup period (3, 6, and 12 months); both groups improved over time. A per-protocol
analysis (excluding these 17 participants) revealed a significant between-group
difference at all follow-up periods. This adjusted (per-protocol) analysis suggested that
in addition to home therapy exercises, acupuncture is superior to ultrasound therapy
for the treatment of shoulder impingement syndrome. The authors concluded,
acupuncture is advocated before ultrasound, in addition to home exercises, for patients with
impingement syndrome.
A trial from the U.S. investigated the benefits of post-operative acupuncture for patients
undergoing arthroscopic acromioplasty (for shoulder impingement syndrome).81 At 3-8
days post-op, participants (n=40) were randomized to receive either 12 acupuncture or
sham acupuncture treatments three times per week for four weeks. Participants in the
acupuncture group received individualized treatments while the sham group received
superficial acupuncture treatments at non-acupoints. Analysis of the primary outcome,
UCLA Shoulder scale (end of treatment and 4 month follow-up), demonstrated a
superiority of acupuncture compared to sham (p<0.0001). Results also indicated benefit
from acupuncture (at both time points) for several secondary measures (VAS pain
intensity, analgesic medication usage, ROM, and most components of the Health Status
Questionnaire). The authors concluded, ...real acupuncture compared to sham offered
significantly greater improvement via: (1) lower pain level, (2) less analgesic use, (3) range of
motion, and (4) patient satisfaction.
Rotator-Cuff Disorders: Tendonitis
A pragmatic trial from Canada warrants comment as it is the only trial conducted on
rotator-cuff tendonitis. The trial compared the effects of naturopathic care (including
acupuncture) and first-line usual care (physical therapy) in postal workers with
diagnosed rotator cuff tendonitis.78 Participants (n=85) were randomized to receive 12weekly treatments of either: naturopathic care (standardized acupuncture combined
with anti-inflammatory supplements and individual dietary advice) or physical therapy
treatment. Both groups demonstrated significant improvements in the primary outcome
(Shoulder Pain and Disability Index) at end of treatment. Between group differences
demonstrated superiority of naturopathic care (acupuncture and herbs) for the
primary (p<0.0001) and secondary outcomes. No post-treatment follow-up was
conducted. The authors concluded, Naturopathic treatment [acupuncture, herbs, dietary
advice] appears to be safe and effective in [the short term]...providing significant benefit over
standard therapy in the treatment of chronic rotator cuff tendinitis...

14

Shoulder Subluxation
A study overlooked in the systematic review of Green et al (2005) is worth mention
since it is the only trial that has investigated the benefits of acupuncture for subluxation
of the shoulder.83 This small (n=20) pilot project investigated if acupuncture adjunctive
to usual care could provide additional benefit for patents who recently suffered a stroke
(mean 22 days). Both groups received standard physiotherapy and occupational
therapy (5/week for 4 weeks). The acupuncture group received a standardized
electroacupuncture protocol at four local acupoints three-times per week (12 total
treatments). Immediately post-treatment the electroacupuncture group demonstrated
statistically significant improvements in VAS shoulder pain (p<0.05) and measurements
of shoulder subluxation (p<0.05; e.g. X-Ray and anthropometry). The authors
concluded, electroacupuncture can be an effective adjuvant in the treatment of shoulder
subluxation for stroke patients.

COMMENTARY
Numerous RCTs have been conducted on the benefits of acupuncture for the treatment
of shoulder pain. A single systematic review summarized trials (through 2003), while
over a dozen RCTs have subsequently been conducted. Individually, the recent trials
can be broadly categorized as investigating either chronic shoulder pain or rotator cuff
disorders. As a whole, the recent evidence appears to more strongly support the
treatment of shoulder pain with acupuncture.
Current allopathic treatment guidelines for shoulder pain recommend 2-3 months of
physiotherapy (e.g. exercise and physical therapy) as well as medication
(e.g. NSAIDs).46 However, the most recent systematic review by the Cochrane
Collaboration concluded that although there is evidence to support physiotherapy in
some instances, ...RCTs of physiotherapy interventions [for shoulder pain] result in little
overall evidence to guide treatment.84 The authors suggest that additional trials
investigating the combined effects of physiotherapy with non-physiotherapy modalities
are warranted.
Many patients with shoulder pain disorders do not respond to usual care and data
suggests that up to 50% of these patients will develop chronic shoulder pain.47,50,51 The
American Academy of Orthopedic Surgeons (AAOS) recommends referral to an
orthopedic specialist if conservative treatment (2-3 months of therapy) is unsuccessful.46
These referrals often lead to corticosteroid injections and, if needed, surgical procedures.
The most recent systematic review on corticosteroid injections for shoulder pain
disorders suggests, little overall evidence to guide treatment85 and is supported by more
recent condition-specific reviews.86,87

15

To date, the two largest trials conducted on the benefits of acupuncture for shoulder
pain were conducted in Germany and Spain.71,73 The German trial suggests a course of
acupuncture treatments is more effective than usual care, ...acupuncture treatments...are
more effective than conventional standard therapy with NSAIDs and physiotherapy.71 The
Spanish trial found that acupuncture was a beneficial adjunct to usual care,
...acupuncture in association with physiotherapy improves shoulder function and alleviates
pain...73 Taken as a whole, these trials suggest that acupuncture, in general, appears to
be an effective option for chronic shoulder pain. It seems warranted to consider
acupuncture in the current AAOS guideline as a component of a multi-modal treatment
approach.

CONCLUSIONS
This Evidence Based Assessment addresses two broad categories related to the
shoulder: chronic shoulder pain and rotator cuff disorders. Based on the evidence,
acupuncture appears to be an effective health care option for the treatment of
generalized shoulder pain. A single systematic review conducted in 2005 notes a
paucity of trials from which to draw conclusions.70 Since the time of that review, over a
dozen clinical trials have been conducted on these two broad categories of shoulder
pain. Since the use of sham acupuncture controls remains controversial,17,88 our
conclusions focus on the pragmatic question: Is acupuncture, either in addition to or in
place of current usual care, an effective treatment option for common shoulder pain
disorders? Of the dozen trials, four included less than 40 participants and are not
summarized.72,75,76,80 Based on the literature, the following condition-specific
conclusions can be drawn.
Chronic Shoulder Pain

The evidence supports the benefit of acupuncture for the treatment of chronic shoulder
pain.
A large RCT (n=424) demonstrates that acupuncture is more effective than
conventional standard therapy (NSAIDs & physiotherapy) with results maintained at
3-month follow-up.71
A large RCT (n=425) demonstrates that acupuncture adjunctive to physiotherapy is
more effective than physiotherapy alone, with results maintained at the 1-year
follow-up.73
A RCT (n=130) demonstrates that acupuncture is more effective than sham treatment
(VAS, pain intensity) at 6-month follow-up.74

16

 The sole (2005) systematic review included trials up to 2003 and was inconclusive, but
suggested: ...acupuncture may provide immediate improvements in both pain and
function...
Rotator Cuff Disorders

The evidence is promising but limited to suggest benefit from acupuncture for the
treatment of rotator cuff tendonitis (tendonosis).
An RCT (n=85) suggests superiority of acupuncture (combined with dietary advice
and herb supplements) on pain and function as compared to physical therapy, with
results maintained at 1-year follow-up.78
The sole (2005) systematic review performed a meta-analysis of two small trials; no
difference was found between acupuncture and sham.70

The evidence is promising but limited to suggest benefit from acupuncture for the
treatment of impingement syndrome.
A single trial (n=117) suggests acupuncture is as effective as corticosteroid injection;
both treatments remained effective at 1-year follow-up.77
A single trial (n=85) suggests acupuncture is superior to ultrasound therapy.79

ACKNOWLEDGEMENTS
None to report.

CONFLICTS OF INTEREST
None to report.

17

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