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).