Acupuncture (Needle Only) Versus Neural Therapy by Huneke (Therapeutic Local Anesthesia) in the Treatment of the Painful Shoulder: Immediate and Long-Term Results (4 Years)

The painful shoulder, or rather the scapulohumeral periarthritis, as it was defined by Duplay in 1872, is a very frequent pain syndrome, including different nosological entities, which is mainly characterized by pain and/or difficulty in usual movements. One of the diagnostic systems identifies various tendinopathies, such as rotator cuff tear, biceps or supraspinatus tendinitis that can evolve in capsulitis of the shoulder (frozen shoulder), and it is widely used, as described by Consensus Group Delphi in 1997 [1]. However, there is a low grade of diagnostic agreement among different practitioners, which in several studies do not reach 50% [2,3]. A widely used classification is the one of Neer [4], who in 1972 defined the disorder as Subacromial conflict syndrome (“impingement syndrome”) and divided it in three stages of increasing severity. According to this etiopathogenetic hypothesis, the rotator cuff (consisting of the subscapularis tendons, the long head of biceps, the infraspinatus, supraspinatus and teres minor), is damaged because of degenerative or traumatic phenomena, causing a deficit in stabilizing and centering the humerus head in the glenoid cavity (glenoid-humerus articulation). The lack of this function leads to the tendency of the humerus head to slide with each arm movement, with a consequent constant microtraumatism of the head of the humerus itself and of the coracoacromial ligament (“conflict” or “impingement”), with further degenerative phenomena of the head of the humerus (erosion, resorption, reactive sclerosis), periarticular inflammatory phenomena with progressive pain worsening. The risk factors for this pathophysiological mechanism are mechanical overload, stress, obesity, age and feminine sex, while sports activities and movement in general are protective factors [5,6]. In addition, psychosocial and individual factors help to develop and maintain the pain pathology [7-8]. The painful shoulder often tends to be selfhealing, but recent studies stress the heavy impact on the quality of life and the serious work and social consequences [9], which in half of the cases at least last several years [10]. Different therapeutic approaches are in use in daily medical practice, but they remain controversial. The most recent critical reviews [11-17] try to find evidence of effectiveness in various therapies, so we do not have sufficient data to assess the examined treatments. In particular, the above-mentioned treatments are non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anesthesia, hydrodilatation, or surgery [14], “corticosteroid injections [15], ultrasound, laser therapy and magnetotherapy [16].

Of all the reflexology and/or complementary techniques, acupuncture is undoubtedly the most studied, which is also the object of a critical review of literature, which concludes that there is little evidence to support or refute the use of acupuncture for shoulder pain [17]. The results obtained by the authors with two reflexology methods - acupuncture [18], or the insertion of needles at certain cutaneous points called acupuncture points, and Neural Therapy (NT) by Huneke [19-23], which is the injection in the same points of low doses of a local anesthetic, almost always procaine or lidocaine in subanesthetic concentration (usually 0.5%) by wheals or intramuscular infiltration, are reported and compared here. Acupuncture is a millenary technique born in China and proved to be particularly useful in the treatment of benign pain [24]. Some Chinese [25-27] and Western [28-32] studies suggest, without conclusive evidence, its possible effectiveness even in the treatment of the painful shoulder. The Neural Therapy (NT) by Huneke is a therapeutic method born in Germany in the ‘20 and practiced with this name in German-speaking countries, even though present in many other countries, such as Latin America and Spain. It consists of infiltration of small doses (0.5-1cc) of local anesthetic at low concentrations (1% procaine or 0.5% lidocaine) in the acupuncture and trigger/tender points (with wheals or intramuscular), as well as in many other anatomical structures such as the arteries and veins, the nervous plexuses or individual peripheral nerves, joints, etc; or in anatomical structures as scars, teeth, tonsils (in order of frequency) etc, when considered “interference fields”. In Englishspeaking countries, the therapeutic use of local anesthetics is widespread, but without the name of “neural therapy”, especially systemically [33], transnasally [34,35] and in trigger/tender points [36,37]. Several studies on neural therapy, although mostly case studies and open studies, suggest their usefulness in musculoskeletal pain [38-40] and the painful shoulder [41,42].

In addition, some studies suggest the same effectiveness of local anesthetics in the therapeutic management of the painful shoulder, if compared with cortisone in subacromial infiltration [43,44], or greater effectiveness when compared with saline in the suprascapular nerve block [45].

From 1982 to 31/8/2007, 275 consecutive cases of painful shoulder were treated by the authors at an Outpatient Pain Therapy Center (58/b Dante Alighieri Avenue, Riva del Garda, Trento, Italy). Informed consent has been obtained from all patients. Patient data have been collected by one of the Authors (BP) in a Microsoft Works database, from which they were drawn out and analyzed for this study. Any acute or chronic benign pain condition, originated from shoulder structures (tendinitis, rotator cuff tears, bursitis, capsulitis), has been considered as “painful shoulder”. “Case” means any therapeutic cycle performed for each shoulder, even on the same patient. Of these 275 cases, 47 were treated with acupuncture and 228 with neural therapy. Frequently used acupuncture points: LI 4 (Shangyang), LI 10 (Shousanli), LI 11 (Quchi), LI 14 (Binao), LI 15 (Jianyu), TE 5 (Waiguan), TE 14 (Jianliao), TE 15 (Tianliao), SI 3 (Houxi), SI 9 (Jianzhen), SI 10 (Naoshu), SI 11 (Tianzong), LU 2 (Yunmen), LU 3 (Tianfu), GB 20 (Fengchi), GB 21 (Jianjing), GB 34 (Yanglingquan), BL 10 (Tianzhu), GV 14 (Dazhui), ST 36 (Zusanli). The anaesthetic used was lidocaine 0.5%, in the amount of 0.5-1cc for each wheal or intramuscular injection. The main techniques used were wheals and/or intramuscular injections in the mentioned acupuncture points and/or tender/trigger points in the aching area and/or in areas of metameric interest of the cervical area or of the arm. In the most refractory cases, the block of suprascapular nerve and of the intra-articular of the shoulder have been used more rarely. The aforementioned “interference field” was not considered nor treated. The analgesic result has been represented as the Percentage of subjective improvement of pain (SPRP = Subjective Pain Relief Percentage) at the end of the treatment cycle and at intervals of 6 months for a follow-up of 4 years; and as TAPR≥2y, consisting of the Time of average persistence of the result in subjects with positive results and at least for 2 years of follow-up [46]. Finally, both groups’ data have been compared by Student t-test for independent samples.

Withdrawn patients, after 1-2 sessions, were 3 (6.4%) in the “acupuncture” group and 8 (3.5%) in the “NT” group (p = n.s.). The two groups left were then examined: group 1 treated with acupuncture (N=44; males = 13 (29.5%)-females=31 (70.5%) and group 2 treated with neural therapy (N=220; males=63 (28.6%)-females=157 (71% ), aged respectively 52.5±16.9 years (range 15-82) and 63.3±14.5 years (range 21 - 95) (p < 0.001), with pain duration of 1 year and 4 months (15.7 months ±36.7 ) (range 0.06 -180 months) and 1 year and 8 months (20.5 months±44) (range 0.03-288 months) (p=n.s.), number of sessions made: 6.5±3.5 (range 1-12) and 6.5±3.6 (range 1-22) (p=n.s.), and duration of the treatment cycle: 30.9± and 25.4 days (range 1-94) and 26.2±21.5 days (range 1-130) (p=n.s.). The analgesic result (Figure 1 & Table1), at the end of the session cycle, was an average percentage of pain improvement (SPRP= subjective pain relief percentage) of 63.9% and 66.2% (p=n.s.). After 6 months, the average percentage of pain improvement was 53.3% (N = 33) and 54.8% (N=163) (p=n.s.); after 1 year, 46.2% (N=32) and 47.6% (N=156) (p=n.s.); after 1 year and 6 months, 46.3% (N=30) and 44.2% (N=142) (p=n.s.); after 2 years, 41% (N=29) and 39.8% (N=135) (p=n.s.); after 2 years and 6 months, 23.5% (N=20) and 40.2% (N=124) (p=n.s.); after 3 years, 24.7% (N=19) and 36.3% (N=110) (p<0.01); after 3 years and 6 months, 23.1% (N= 16) and 32,5,3% (N=110 ) (p=n.s.); after 4 years, 24.7% (N=15) and 28.7% (N=108) (p=n.s.). The Time of average persistence of the result in the cases with a positive result and with follow-up over two years (TAPR≥2y) was 27.4 months ±28.2 (N=21) in group 1, and 37.8 months ±46.8 (N=128) in group 2 (p=n.s.) (Figure 2). In addition, any accidents, complications and side effects using the two techniques have not been observed in both groups.

Figure 1:Immediate and long-term (4 years) analgesic results (Subjective Pain Relief Percentage=SPRP) in the groups “acupuncture” and “neural therapy” (n.s.=Not Significant).

Table 1:Results as “Subjective Pain Relief Percentage” (SPRP) every three months up 4 years

*N=number of patients.

Figure 2:Time of average persistence of result with at least 2 years of follow-up (TAPR≥2y) in the groups “acupuncture” and “NT”=Neural Therapy).

This is a retrospective study, so it does not consider any control group, also for the practical difficulty of creating a group of patients not treated or on the waiting list for a private outpatient center as the Author-s one. Therefore, we decided to compare the results obtained by neural therapy, a therapeutic technique practiced a lot in the German and Spanish-speaking countries, but with few specific studies on shoulder pains, and no randomized controlled trials, with those obtained in a smaller control group treated by the same Authors by Chinese acupuncture, a similar technique, in particular in the choice of the points to be treated. The Chinese acupuncture in fact is a therapeutic technique certainly more studied on shoulder pains [25-32], also with randomized controlled trials [27-29], and probably effective, even if not conclusively [15]. At the end of the treatment cycle (immediate result) and up to two years of follow-up, the analgesic result, for both the considered methods of therapy appear similar, while in the following two years the results with neural therapy are better, although this difference is not statistically significant, especially for the narrowness of the group treated with acupuncture. When it comes to the other index of analgesic effectiveness, the Time of average persistence of result (TAPR≥2y), it has been detected much better in the neural therapy group. In this group, the positive results lasted about 3 years vs the 2 years of the acupuncture group. Also, in this case the narrowness of the acupuncture group (N=21) has not allowed the detection of a statistically significant difference.

However, it must be considered that, the number of the sessions, the duration of the therapy and the duration of pain were equal in the two groups, but the neural therapy group was older than the acupuncture group (63 years vs. 52; p<0,001). Being age a negative factor for analgesic outcomes in prognostic terms [47], this data must be regarded as an additional advantage to ascribe to neural therapy, which therefore, in our opinion should be considered superior to acupuncture, in terms of analgesic outcome. Desipte in literature severe complications due to the two described techniques are reported, in particular concerning neural therapy, when particularly invasive like in some anaesthetic blocks of deep structures [48,49], in this study complications have not been reported, also because of the use of minimally invasive neural therapy techniques, essentially subcutaneous wheals and/ or intramuscular of trigger/tender points. The two reflexology techniques discussed here were, in this study, easy-to-perform, harmless, and low-cost, all features that, together with the potential effectiveness, candidate them to be considered as valid therapeutic options of choice for the outpatient’s context. Finally, it must be considered, that in literature there are no other studies comparing acupuncture and neural therapy in the treatment of the painful shoulder. Similar retrospective comparative studies by the same authors, in benign lumbago [50], cervicalgia [51] and headaches [52], are in favour of a slight superiority of neural therapy.

In conclusion, the analgesic results were almost always (13 times out of 18) better for the neural therapy group, even though they do not show as statistically different, probably due to the small number of cases treated with acupuncture. Furthermore, there is an additional advantage for the neural therapy: the cases treated with this method were older, a negative factor in prognostic terms. This study represents the first attempt to compare the analgesic results of two widely used but still not much studied methods, in particular neural therapy by Huneke, for the treatment of periarticular pain of the shoulder. Anyway, the results obtained with the two methods are promising and such as to include the methods, among the therapies of choice in case of shoulder pain also for their safety and low cost However, further studies are deemed necessary, in particular prospective and randomized trials with control group, to define the real effectiveness of the two methods, and to determine which of the two is the best one.

The authors declare that they have no competing interests.

PB and FC participated in the design of the study, performed acquisition, analysis and interpretation of data, statistical analysis and drafted the manuscript. RB participated in the acquisition of data and VG contributed to the drafting and translation of the manuscript. All the authors read and approved the final manuscript.

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