Shoulder pain is the third most common musculoskeletal complaint that necessitates physician consultation and significantly diminishes patients’ quality of life. In this review, we analyzed clinical studies that investigated the use of Korean Medicine for the treatment of shoulder pain.

Methods

We searched the online Korean databases, such as KMBase, DBpia, NDSL, RISS, KISS, and OASIS for clinical studies that report the use of Korean Medicine for shoulder pain. We analyzed the included studies with regard to study design, interventions, evaluations, and results.

Results

We analyzed data from the following 29 studies: 14 clinical trials (which included 9 randomized controlled trials) and 15 observational studies (which included 11 case reports). In this review, we observed that post-stroke shoulder pain was the most common cause of shoulder pain, which was reported in 13 out of 29 studies (44.8%), although in actual clinical practice, patients are more likely to present with primary shoulder pain. Most included studies (72.4%) reported manual acupuncture as the most common intervention for shoulder pain. More than 50% of the studies used range of motion (58.6%) and the numeric rating scale (51.7%) to evaluate shoulder function and pain, respectively. Although the result was not statistically significant in all included studies, most studies concluded that Korean Medicine could be considered an effective treatment option in patients with shoulder pain.

Conclusions

Based on analysis of studies included in this review, Korean Medicine can be considered useful clinical treatment for shoulder pain.

Keywords: Shoulder pain; Korean Medicine; Review

Fig. 1

Flow Diagram of Study Selection

Fig. 2

Number of Clinical Studies Published by Years

Fig. 3

Risk of Bias Graph

Fig. 4

Risk of Bias Summary

Fig. 3

Case Reports According to The Quality of Reporting Evaluated by Each Item of CARE Guidelines

Table 1

Search Formula

Table 2

Number of Clinical Studies Published by Journals

Table 3

Composition of Interventions

Table 4

Percentage of items Recording according to CARE Guide by Each Case Report

Table 5

Percentage of Case Reports with Reporting Items of CARE Guide by Each Item

Table 6

Charateristics of Clinical Studies

Table 7

Acupoints Classification by Distance to Site of Pain

Table 8

Frequency of Meridians Used

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Article information Continued

Fig. 1

Flow Diagram of Study Selection

Fig. 2

Number of Clinical Studies Published by Years

Fig. 3

Risk of Bias Graph

Fig. 4

Risk of Bias Summary

Fig. 3

Case Reports According to The Quality of Reporting Evaluated by Each Item of CARE Guidelines

Table 1

Search Formula

Database	Search Formula	Number of Results
KMbase	((([ALL=어깨통증] OR [ALL=어깨관절 통증]) OR [ALL=견통]) OR [ALL=견관절통])) AND(((((((([ALL=한방] OR [ALL=한의]) OR [ALL=침]) OR [ALL=약침]) OR [ALL=봉침]) OR [ALL=뜸]) OR [ALL=부항]) OR [ALL=추나])	9
DBpia	전체=( 어깨통증 \| 어깨관절 통증 \| 견관절통 \| 견통) AND 전체=( 한방 \| 침 \| 약침 \| 봉침 \| 뜸 \| 부항 \| 추나)	12
NDSL	Advanced search, 국내논문, whole field (어깨통증 \| 어깨관절 통증 \| 견관절통 \| 견통) AND (한방 \| 한의 \| 침 \| 약침 \| 봉침 \| 뜸 \| 부항 \| 추나)	43
RISS	전체 : (어깨통증 \| 어깨관절 통증 \| 견관절통 \| 견통) <AND> 전체: (한방 \| 한의 \| 침 \| 약침 \| 봉침 \| 뜸 \| 부항 \| 추나)	60
KISS	전체 = (어깨통증 \| 어깨관절 통증 \| 견관절통 \| 견통) AND 전체 = (한방 \| 한의 \| 침 \| 약침 \| 봉침 \| 뜸 \| 부항 \| 추나)	27
OASIS	어깨통증 \| 어깨관절 통증 \| 견관절통 \| 견통	28

Table 2

Number of Clinical Studies Published by Journals

Name of Journal	Number of Publication
Journal of Acupuncture Research	6
Journal of Korean Medicine Rehabilitation	4
Journal of Pharmacopuncture	4
Journal of Korean Medicine	3
Journal of Haehwa Medicine	3
The Journal of Internal Korean Medicine	2
The Journal of Korea CHUNA Manual Medicine for Spine & Nerves	2
The Journal of Jeahan Oriental Medical Academy	1
The Journal of the Society of Stroke on Korean Medicine	1
Korean Journal of Acupuncture	1
Journal of Oriental Medical Thermology	1
Graduate School of Engineering KonKuk University	1

Table 3

Composition of Interventions

Pharmacopuncture
Name	Composition
Jungsongouhyul pharmacopuncture	梔子(Gardeniae Fructus), 玄胡索(Corydalis Rhizoma), 乳香(Olibanum), 沒藥 (Myrrha), 桃仁(Persicae Semen), 赤芍藥(Paeoniae Radix Rubra), 丹蔘(Salviae Miltiorrhizae Radix), 蘇木(Sappan Lignum)
Hwangryunhaedok-tang pharmacopuncture	黃芩(Scutellariae Radix), 黃蓮(Coptidis Rhizoma), 黃柏(Phellodendri Cortex), 梔子(Gardeniae Fructus)
Zingiberis rhizoma herbal acupuncture	生薑(Zingiberis Rhizoma Recens)
Ligamentum pharmacopuncture	膠飴(Saccharum Granorum), 白芷(Angelicae Dahuricae Radix)
Herbal Topical Gel
Dapureo gel	蓮子肉(Nelumbinis Semen), 薄荷(Menthae Herba), 黃蓮(Coptidis Rhizoma), 甘菊(Chrysanthemi Flos), 酸棗仁(Zizyphi Spinosae Semen), 遠志(Polygalae Radix), 石菖蒲(Acori Graminei Rhizoma), 香附子(Cyperi Rhizoma), 竹茹(Bambusae Caulis In Taeniam) 白茯神(Hoelen cum Pini Radix) etc.

Table 4

Percentage of items Recording according to CARE Guide by Each Case Report

Case Reports	Reporting						Not-Reporting

	Sufficient		Not-Sufficient
1st author (year)	n1/N	%	n2/N	%	(n1+n2)/N	%	n3/N	%
Han MG(2000)	16//28	57.14	7/28	25.00	23/28	82.14	5/28	17.85
Shin WY(2006)	16/28	57.14	7/28	25.00	23/28	82.14	5/28	17.85
Kim JH(2011)	18/28	64.28	3/28	10.71	21/28	75.00	7/28	25.00
Kim NH(2011)	11/28	39.28	9/28	32.12	20/28	71.42	8/28	28.57
Jung YG(2012)	17/28	60.71	3/28	10.71	20/28	71.42	8/28	28.57
Lee SJ(2014)	14/28	50.00	8/28	28.57	22/28	78.57	6/28	21.42
Lee HJ(2016)	12/28	42.85	8/28	28.57	20/28	71.42	8/28	28.57
Song KC(2017)	15/28	53.57	5/28	17.85	20/28	71.42	8/28	28.57
Lim HC(2017)	13/28	46.42	9/28	32.12	21/28	75.00	6/28	21.42
Seo HJ(2017)	19/28	67.85	4/28	14.28	23/28	82.14	5/28	17.85
Jeong SJ(2017)	16/28	57.14	6/28	21.42	22/28	78.57	6/28	21.42

1) ‘n1’, ‘n2’, and ‘n3’ mean the number of which items match each assessment-criteria: Sufficient, Not-Sufficient and Not-Reporting, respectively.

2) ‘N’ means the number of applicable items.

Table 5

Percentage of Case Reports with Reporting Items of CARE Guide by Each Item

Section		Item description	Sufficient		Not-Sufficient		Not-Reporting
Section		Item description	n/N	%	n/N	%	n/N	%
Title	1	The words “case report” should be in the title along with phenomenon of greatest interest	5/11	45.45	6/11	54.54^*	-	-
Key word	2	The key elements of this case in 2–5 words.	8/11	72.72	3/11	27.27	-	-
Abstract	3a	Introduction-What does this case add?	7/11	63.63	4/11	36.36	-	-
	3b	Case presentation: - The main symptoms of the patient - The main clinical findings - The main diagnoses and interventions - The main outcomes	5/11	45.45	6/11	54.54^*	-	-
	3c	Conclusion-What are the main “take-away” lessons from this case?	9/11	81.81	2/11	18.18	-	-
Introduction	4	Brief background summary of the case referencing the relevant medical literature.	10/11	90.90	1/11	9.09	-	-
Patient information	5a	Demographic information of the patient (age, gender, ethnicity, occupation)	10/11	90.90	1/11	9.09	-	-
	5b	Main symptoms of the patient (his or her chief complaints)	10/11	90.90	1/11	9.09	-	-
	5c	Medical, family, and psychosocial history-including diet, life style and genetic information whenever possible and details about relevant comorbidities and past interventions and their outcomes	4/11	36.36	6/11	54.54^*	-	-
Clinical findings	6	Describe the relevant physical examination (PE) and other significant clinical findings.	9/11	81.81	2/11	18.18	-	-
Timeline	7	Depict Important dates and times in the case (table or figure)	1/11	9.09	9/11	81.81^*	1/11	9.09
Diagnostic assessment	8a	Diagnostic methods (such as PE, laboratory testing, imaging, questionnaires)	9/11	81.81	2/11	18.18	-	-
	8b	Diagnostic challenges (such as financial or language/cultural)	-	-	-	-	11/11	100.00^*
	8c	Diagnostic reasoning including other diagnoses considered	5/11	45.45	4/11	36.36	2/11	18.18
	8d	Prognostic characteristics (such as staging in oncology) where applicable	2/11	18.18	2/11	18.18	7/11	63.63^*
Therapeutics interventions	9a	Types of intervention (such as pharmacologic, surgical, preventive, self-care)	11/11	100.00	-	-	-	-
	9b	Administration of intervention (such as dosage, strength, duration)	5/11	45.45	6/11	54.54^*	-	-
	9c	Changes in intervention (with rationale)	1/11	9.09	5/11	45.45	5/11	45.45
Follow-up and outcomes	10a	Clinician and patient-assessed outcomes (when appropriate)	10/11	90.90	1/11	9.09	-	-
	10b	Important follow-up diagnostic evaluations and other test results (positive or negative)	10/11	90.90	1/11	9.09	-	-
	10c	Intervention adherence and tolerability (and how this was assessed)	-	-	-	-	11/11	100.00^*
	10d	Adverse and unanticipated events	-	-	-	-	11/11	100.00^*
Discussion	11a	Strengths and limitations of the management of this case-with references	10/11	90.90	1/11	9.09	-	-
	11b	Relevant medical literature	11/11	100.00	-	-	-	-
	11c	Rationale for conclusions (including assessment of cause and effect)	6/11	54.54	5/11	45.45	-	-
	11d	Main “take-away” lessons of this case report	9/11	81.81	-	-	2/11	18.18
Patient perspective	12	The patient should share their perspective or experience whenever possible.	-	-	-	-	11/11	100.00^*
Informed consent	13	Did the patient give informed consent? Please provide if requested.	-	-	-	-	11/11	100.00^*

1) ‘n’ means the number of which case reports match each assessment criteria of items: Sufficient, Not-Sufficient, Not-Reporting, respectively.

2) ‘N’ means that the number of case reports having applicable items.

3) ‘^*’ means that the percentage of not-reporting items or not-sufficiently reporting items more than 50%

Table 6

Charateristics of Clinical Studies

First author (year)	Study design	Sample size(T:C)	Casuses	Treatment intervention	Control intervention	Treatment period	Outcome measures	Effective results
Lee (1999)	RCT	40 (20:20)	Post stroke	Taping, ATx	ATx	3 weeks 2/a week	1) VAS 2) ROM 3) Motor grade	1) p<0.05 2) p>0.05 3) p>0.05
Yin (2000)	RCT	24 (12:12)	Post stroke	BVP, H-med, ATx, PTx.	H-med, ATx. PTx.	4 weeks 3/a week	1) VAS 2) ROM 3) FMMA 4) MAS	1) p<0.01 2) p<0.01 3) p<0.05 4) p>0.05
Bae (2004)	RCT	43 (21:22)	Post stroke	JSP, H-med, ATx,PTx.	N/S inj, H-med, ATx, PTx	1 week 3/a week	1) VAS 2) Motor grade 3) MBI 4) NIHSS 5) AI	1) p<0.05 2) p>0.05 3) p>0.05 4) p>0.05 5) p>0.05
Cho (2005)	RCT	23 (12:11)	Post stroke	ZR, H-med, ATx, PTx.	BVP, H-med, ATx, PTx.	2 weeks 7/a week	1) VAS 2) ROM 3) MMT	1. ZR 1) p<0.05 2) Add, Flx p<0.05 Abd, Ext p>0.05 3) p<0.05 2. BVP 1) p<0.05 2) p<0.05 3) p<0.05
Eom (2006)	RCT	30 (10:10:10)	Post stroke	1. BVA 2. BVP	ATx.	4 weeks 3/a week	1) VAS 2) ROM 3) FMMA 4) MAS	1. BVA 1) p<0.05 2) p<0.05 3) p<0.05 2. BVP 1) p<0.05 2) p<0.05 3) p<0.05 3. ATx. 1) p<0.05 2) p<0.05 3) p<0.05
Ko (2007)	RCT	46 (24:22)	Post stroke	BVP, H-med, ATx, PTx, Mox	N/S inj, H-med, ATx, PTx, Mox	2 weeks 3/a week	1) VAS 2) PRS 3) ROM 4) FMMA	1) p<0.05 2) p<0.05 3) p<0.05 4) p<0.05
Park (2011)	RCT	40 (21:19)	Post stroke	BVP	N/S inj.	4 weeks 3/a week	1) VAS 2) PRS 3) ROM 4) FMMA	1) p<0.05 2) p<0.05 3) p<0.05 4) p<0.05
Jo (2014)	RCT	30 (15:15)	UC	Dapureo Gel	Water Gel	2weeks 7/a week	1) VAS 2) SPADI	1) p<0.001 2) p<0.05
Ji (2014)	RCT	17 (9:8)	Acute trauma	JSP	EA	2 weeks 3/a week	1) VAS 2) ROM	1. JSP 1) p<0.05 2) p<0.05 2. EA 1) p<0.05 2) p<0.05
Yoon (2006)	nRCT	44 (24:20)	Muscle tension	Intradermal ATx.	No intervention	2 weeks 2/a week	1) VAS 2) Self-rating pain sensitivity	1) p=0.000 2) p=0.000
Shin (1998)	Before-After Study	21	Post stroke	H-med, ATx, PTx.	-	2 weeks ~ over 16 weeks	1) ROM 2) Motor grade	Improved (without p-value)
Kim (2009)	Before-After Study	20	UC	Dry cupping therapy	-	1 week 2/a week	1) VAS 2) ROM	1) p<0.01 2) Flx p<0.01 Ext p<0.05 Abd, Int Ro, Ext Ro. p>0,05
Park (2010)	Before-After Study	15	Muscle tension	Low level laser therapy	-	2 weeks 4/a week	1) Self-rating pain sensitivity 2) SPADI 3) PPT	1) p<0.01 2) p<0.01 3) p<0.01
Sohn (2011)	Before-After Study	27	Muscle tension	Dry cupping therapy	-	2 weeks 2/a week	1) VAS 2) Frequency of pain	1) p<0.001 2) p<0.001
Han (2000)	Case report	1	Post stroke	ATx, Mox, PTx	-	Over 8months	ROM	Improved
Shin (2006)	Case report	3	Post stroke	H-med, ATx, Dry cupping therapy, PTx.	-	1. 1 month 2. 1 week 3. 1 week	VAS	1. 7.5→1.5 2. 10→3.5 3. 6→3
Kim (2011)	Case report	9	Post stroke	H-med, ATx, EA, Mox	-	10~34 days	1) PRS 2) ROM	1) p<0.05 2) p<0.05
Kim (2011)	Case report	1	Calcific tendinitis	H-med, ATx, EA, Mox, JSP	-	12 days 1/a day	1) VAS 2) SPADI 3) UCLA-score	1) 9→4 2) 92→48 3) 6→13
Jung (2012)	Case report	3	Impingement Syndrome	H-med, ATx, HHP,	-	1) 10 days 2) 12 days 3) 9 days	1) NRS 2) ROM 3) P/E	1. 1) 10→3 2. 1) 10→1 3. 1) 10→1
Lee (2014)	Case report	2	Partial tear of SSP	ART, H-med, ATx, BVP, PTx.	-	1 month	1) VAS 2) ROM 3) P/E	1.1) 9→2 2.1) 5→2
Lee (2016)	Case report	1	Muscle tension	ATx.	-	1 day	1) NRS 2) PPT 3) ROM	1) 5→2 2) left: 19N→22N right: 22N→27N 3) no change
Song (2017)	Case report	4	SSP tendinitis, SASD bursitis	H-med, ATx, SP	-	13~19 days	1) NRS 2) ROM 3) SPADI 4) P/E	1. 1) 10→1 3) 53.85→10 2. 1) 10→2 3) 75.2→11.54 3. 1) 10→1 3) 58.85→5.38 4. 1)10→2 3) 60→10
Lim (2017)	Case report	1	Post stroke	H-med, ATx, JSP, Dry cupping therapy, PTx.	-	2 months	1) NRS 2) MMT	1) 10→2 2) 3/4→4/5
Seo (2017)	Case report	1	Post stroke	H-med, ATx, Mox, EA	-	23 days	1) NRS 2) Awakening time	1) 7→2 2) 5→1
Jeong (2017)	Case report	4	Muscle tension	H-med, ATx, EA, BVP, LP, PTx.	-	5~16 days	1) NRS 2) ROM 3) SPADI	1. 1) 8→3 3) 70→46.15 2. 1) 6→1 3) 23.07→5.384 3. 1) 9→5 3) 50.76→39.23 4. 1) 6→2 3) 60→40
Chae (1987)	Case series	44	UC	H-med, ATx, PTx	-	Under 1 week ~ over 4 weeks	1) VAS 2) ROM	TER=68.1%
Sin (1998)	Case series	3700	UC	H-med, ATx, Dry cupping therapy, PTx.	-	UC	Subjective evaluation	TER=87.6%
Lim (2014)	Case series	28	SASD bursitis, SSP partial tear, Adhesive capsulitis, AC joint arthropathy, SSP tendinosis, Sheath of long bicipital tendon ganglion cyst, SSP full thickness tear, SSC partial tear, ISP partial tear, SSP calcific tendinitis, SLAP lesion, SSC tendinosis, ISP full thickness tear, ISP calcific tendinitis, SSC tendinitis etc.	H-med, ATx, EA, SP	-	Over 2 weeks 2/a day	1) NRS 2) ROM	1) 6.36→3.50 2) Flx 150→164.20, Abd 143.57→160.36, Int Ro. 73.04→78.39, Ext. Ro. 69.812→78.39
Lee (2015)	Case series	410	Sprain, Rotator cuff injury, Adhesive capsulitis, SLAP & Biceps tendon injury, Calcific tendinitis, Shoulder arthrosis		-	Variant, average 9.17 days	Subjective symptom, ROM	TER=75.12%

T: Treatment group, C: Control group, UC: Unclear, ATx: Acupuncture treatment, BVP: Bee venom pharmacopuncture, H-med: Herbal medicine, PTx: Physical therapy, JSP: Jungsongouhyul pharmacopunture, N/S: Normal saline, ZR: Zingiberis rhizoma herbal acupuncture, Abd: Abduction, Add: Adduction, Flx: Flexion, Ext: Extension, BVA: Bee venom Acupuncture, Mox: moxibustion, EA: Electroacupuncture, Int Ro: Internal rotation, Ext Ro: External Rotation, HHP: Hwangryunhaedok-tang pharmacopuncture, ART: Active release technique, SP: Shinbaro pharmacopuncture, LP: Ligamentum pharmacopuncture, TER: Total effective rate, SSP: Supraspinatus, SASD: Subacromial-subdeltoid, AC: Acromioclavicular, ISP: Infraspinatus, SSC: Subscapularis

Table 7

Acupoints Classification by Distance to Site of Pain

Local acupoints	Distal acupoints
肩髃(LI15), 肩井(GB21), 肩髎(TE14), 臑兪(SI10), 天宗(SI11), 巨骨(LI16), 秉風(SI12), 肩外兪(SI14), 曲垣(SI13), 肩中兪(SI15), 臂臑(LI14), 肩前(EX-UE), 肩貞(SI9)	曲池(LI11), 外關(TE5), 合谷(LI4), 太衝(LR3), 足三里(ST36), 懸鍾(GB39), 三陰交(SP6), 百會(GV20), 後谿(SI3), 風市(GB31), 陽陵泉(GB34), 陰陵泉(SP9), 條口(ST38), 風池(GB20), 中㵭(TE3), 地倉(ST4), 頰車(ST6), 八風(EX-LE10), 八邪(EX-UE9), 天髎(TE15), 太谿(KI3), 水泉(KI5), 照海(KI6), 復溜(KI7), 交信(KI8), 築賓(KI9), 太白(SP3), 太淵(LU9), 魚際(LU10), 少府(HT8), 大敦(LR1), 陰谷(KI10), 少海(HT3), 少衝(HT9), 承山(BL57), 水溝(GV26), 委中(BL40), 申脈(BL62), 曲鬢(GB7), 崑崙(BL60), 承漿(CV24), 手三里(LI10), 下巨虛(ST39)

Local acupoints

Distal acupoints

肩髃(LI15), 肩井(GB21), 肩髎(TE14), 臑兪(SI10), 天宗(SI11), 巨骨(LI16), 秉風(SI12), 肩外兪(SI14), 曲垣(SI13), 肩中兪(SI15), 臂臑(LI14), 肩前(EX-UE), 肩貞(SI9)

曲池(LI11), 外關(TE5), 合谷(LI4), 太衝(LR3), 足三里(ST36), 懸鍾(GB39), 三陰交(SP6), 百會(GV20), 後谿(SI3), 風市(GB31), 陽陵泉(GB34), 陰陵泉(SP9), 條口(ST38), 風池(GB20), 中㵭(TE3), 地倉(ST4), 頰車(ST6), 八風(EX-LE10), 八邪(EX-UE9), 天髎(TE15), 太谿(KI3), 水泉(KI5), 照海(KI6), 復溜(KI7), 交信(KI8), 築賓(KI9), 太白(SP3), 太淵(LU9), 魚際(LU10), 少府(HT8), 大敦(LR1), 陰谷(KI10), 少海(HT3), 少衝(HT9), 承山(BL57), 水溝(GV26), 委中(BL40), 申脈(BL62), 曲鬢(GB7), 崑崙(BL60), 承漿(CV24), 手三里(LI10), 下巨虛(ST39)

Acupoints only used in one of the studies are in italics.

Table 8

Frequency of Meridians Used

Meridians	Acupoints	Number of acupoints
Taiyang Small Intestine Channel of Hand (手太陽小腸經)	後谿(SI3), 臑兪(SI10), 天宗(SI11), 秉風(SI12), 肩外兪(SI14), 曲垣(SI13)	6
Shaoyang Gallbladder Channel of Foot (足少陽膽經)	懸鍾(GB39), 風市(GB31), 陽陵泉(GB34), 風池(GB20), 肩井(GB21)	5
Yangming Large Intestine Channel of Hand (手陽明大腸經)	曲池(LI11), 合谷(LI4), 肩髃(LI15), 巨骨(LI16)	4
Shaoyang Sanjiao Channel of Hand (手少陽三焦經)	外關(TE5), 中㵭(TE3), 肩髎(TE14)	3
Yangming Stomach Channel of Foot (足陽明胃經)	足三里(ST36), 條口(ST38)	2
Taiyin Spleen Channel of Foot (足太陰脾經)	三陰交(SP6), 陰陵泉(SP9)	2
Jueyin Liver Channel of Foot (足厥陰肝經)	太衝(LR3)	1
Governing Vessel (督脈)	百會(GV20)	1

The acupoints in this table are used in two or more studies.