Interventions
A multimodal rehabilitation protocol including physiotherapy and
exercise treatments was applied jointly to both groups. This protocol
consisted of a total of 15 sessions for three weeks, five sessions per
week. On the first, eighth, and fifteenth days of the treatment, three
sessions of DN were additionally performed on the conventional
treatment–DN combination group.
The conventional rehabilitation protocol included 20 min of hot packs,
30 min of high-intensity transcutaneous electrical nerve stimulation,
and 30 min of exercise per session. The exercise protocol incorporated
the entire upper extremity on the affected side, including the patient’s
shoulder, elbow, and wrist. Initially, flexion, abduction, extension,
moderate external rotation, and internal rotation movements of the
shoulder region were performed passively by the physiotherapist.
Movements were performed at the pain limit in order to prevent rotator
cuff damage during the abduction movement. Then, mobilization exercises
for the glenohumeral and scapulothoracic joints were added. The active
range of motion exercises and isometric strengthening exercises for the
shoulder abductors and elbow flexors were added to the treatment program
in patients with a manual muscle test greater than 3/5. Walking,
balance, and coordination exercises with an assistive device were also
included in the rehabilitation program.
DN treatment was administered by a physician (F.B) with eight years of
experience. First, active MTrPs in the muscles were identified through a
physical examination. The area to be treated was cleaned with alcohol.
The Seirin J-type sterile acupuncture needles (Seirin Corporation,
Shizuoka, Japan) for the upper trapezius, subscapularis, supraspinatus,
infraspinatus, teres minor, pectoralis major, and biceps brachii muscles
targeted and penetrated the skin. Intramuscular navigation was performed
until a local twitch response was obtained. If there was more than one
trigger point in a muscle, the treatment was applied to the most painful
point. After the needle was removed, a localized hematoma was prevented
by applying pressure with cotton for 1 min. DN was performed in the
prone position for the upper trapezius, infraspinatus, teres minor, and
subscapularis muscles; supine position for the pectoralis major muscle;
and side-lying position for the supraspinatus (Figure 2).