Chiropractic & Osteopathy 2005 (Sep 16); 13 (1): 20 ~ FULL TEXT
Mario Pribicevic and Henry Pollard
Macquarie Injury Management Group Department of Health and Chiropractic Macquarie University, 2109, Sydney Australia
Background: This paper describes the clinical management of four cases of shoulder impingement syndrome using a conservative multimodal treatment approach. Clinical Features: Four patients presented to a chiropractic clinic with chronic shoulder pain, tenderness in the shoulder region and a limited range of motion with pain and catching. After physical and orthopaedic examination a clinical diagnosis of shoulder impingement syndrome was reached. The four patients were admitted to a multi-modal treatment protocol including soft tissue therapy (ischaemic pressure and cross-friction massage), 7 minutes of phonophoresis (driving of medication into tissue with ultrasound) with 1% cortisone cream, diversified spinal and peripheral joint manipulation and rotator cuff and shoulder girdle muscle exercises. The outcome measures for the study were subjective/objective visual analogue pain scales (VAS), range of motion (goniometer) and return to normal daily, work and sporting activities. All four subjects at the end of the treatment protocol were symptom free with all outcome measures being normal. At 1 month follow up all patients continued to be symptom free with full range of motion and complete return to normal daily activities.
CONCLUSIONS: This case series demonstrates the potential benefit of a multimodal chiropractic protocol in resolving symptoms associated with a suspected clinical diagnosis of shoulder impingement syndrome.
Key Words: Shoulder, Impingement Syndrome, Multi-modal Treatment, Chiropractic
From the FULL TEXT Article:
Alerting features of a possible serious condition (red flag), which may present with shoulder pain [7,8].
|POSSIBLE SERIOUS CAUSES OF SHOULDER PAIN (RED FLAGS)
|Signs of infection (fever)
|History of drug abuse
||Pain at rest
|Age over 50
|History of previous malignancy
||History of fall
|Constant, non mechanical pain
||No precipitating event (for onset)
|Palpable deformities of bone/tissue
|Widespread neurological symptoms/signs
Pribicevic and Pollard Chiropractic & Osteopathy 2005 13:20 doi:10.1186/1746-1340-13-20
Discussion and Conclusions
Rotator cuff impingement and or tendonosis is a common disorder encountered in a primary health care setting [12-15]. Perhaps, less in chiropractic practises as opposed to medical and physiotherapy. To date, there are no data investigating the prevalence of shoulder pain in the chiropractic setting. This may be due to the lack of general public awareness about the scope and capabilities of chiropractors to be involved in management of non-spinal disorders or simply the public making another choice. This condition presents a challenge to the chiropractor due to its prevalence, and its possible close interrelationship with the spine.
A major reason for documenting this treatment protocol is to encourage the development of future clinical guidelines for chiropractors and to encourage the expansion of their treatment range to include peripheral disorders.
Another goal of this report is to highlight that multimodal management is often required to address the painful shoulder and not to determine or show which treatment approach or particular therapy was more effective. The four patients in this paper were managed with a treatment protocol that included a number of therapies. The literature [16-22] suggests that the multimodal approach is an appropriate method for the successful conservative management of shoulder problems.
The cervical and thoracic spines should be reviewed as a possible factor associated with rotator-cuff dysfunction. As an example consider the slumping posture in a competitive swimmer. Others and we hypothesise that the rounded shoulders and increased thoracic kyphosis places increased demands on the rotator cuff and contributes to the impingement process . A possible mechanism for this hypothesis is as follows: the posture may alter the mechanical function (orientation) of the scapula and humerus, leading to muscular imbalances, abnormal movement patterns during glenohumeral elevation with associated weakness of the posterior cuff muscles. Therefore this may lead to a loss of force couple at the glenohumeral joint with resultant repetitive humeral head impingement [23-25].
The outcome measures for the study included improvement of pain, return to pre-treatment activities, and restoration of full active and passive movements. The outcome measures were mainly subjective in nature and dependent on the response of the patients and the practitioner's skill in conducting the orthopaedic reassessment, therefore allowing an element of examination bias. This particular shortcoming may be improved by using more sensitive scoring systems that can be accurately reproduced by different observers such as the subjective shoulder rating system , UCLA scoring system , or the highly sensitive Constant/Murley functional assessment of the shoulder .
Although frequently advocated for outcomes based assessment, goniometric measurement for the shoulder remains questionable. Williams et al  studied 22 observers who used three different types of goniometers to assess the range of abduction and visual estimation. The results demonstrated visual estimation to be the most reliable method. Moderate inter-observer reliability was also demonstrated in a study by Bostrom et al  where range of motion was measured using a goniometer.
This report presents an approach that combines aspects of traditional forms of chiropractic, physiotherapy and medicine in the conservative management of certain shoulder pain.
The individual therapies that were used in this multimodal treatment protocol have been shown to be useful in the management of shoulder pain both singularly and in combination [18,19,31-36].
Of the electro-modalities the apparatus used was ultrasound. Some authors routinely advocate the usage of ultrasound in conjunction with other modalities and report positive outcomes [3,16,35]. The physiologic benefits of ultrasound have been attributed to its thermal actions; these involve an increase in peripheral blood flow, increased tissue metabolism and greater tissue extensibility .
The use of ultrasound for shoulder pain and its effect on soft tissue structures of the shoulder has been studied extensively in the literature. A recent study by Nykanen  investigating pulsed ultrasound treatment of the painful shoulder in a randomised, double blind and placebo controlled study, showed no differences in outcome between the treatment and placebo groups at the end of the trial period. However, when the ultrasound was used to complement treatment the patients reported a significant subjective improvement in symptoms. A further study by Downing , and Perron et al , also showed no apparent benefit from ultrasound therapy. None of these studies demonstrated statistically significant results supporting ultrasound therapy. A recent review of the literature conducted by Van der Windt  also concluded that there is little evidence that ultrasound therapy is effective for soft tissue disorders of the shoulder. By contrast to the above studies the subjects in this paper were treated with a 3MHz setting plus phonophoresis that may have influenced the outcome measures. Nevertheless the efficacy and effectiveness of ultrasound for shoulder pain remains in doubt.
In this study the subjects were also treated with an ultrasound technique known as phonophoresis. Phonophoresis involves the movement of a medication through intact skin into the underlying soft tissue, by ultrasonic pertubation . By using ultrasound a topical corticosteroid cream can be successfully delivered across the skin with a view to reducing the inflammation and pain associated with the more superficial soft tissue injuries and disorders . Davick  showed in his study corticosteroid medication penetration through to the epidermal layer of skin, and further into the stratum corneum. The medication used to treat the subjects was a topical corticosteroid – Sigmacort 1%. This approach combined with the therapeutic effects of ultrasound appeared subjectively to have a beneficial effect as a treatment adjunct.
There is some evidence reporting the positive effects of phonophoresis. Griffin et al  conducted a double blind study comparing the effects of phonophoresis and ultrasound in 102 patients with various shoulder complaints. Of the subjects receiving phonophoresis 68% showed significant improvement in range of motion and pain as opposed to 28% in the ultrasound group.
In 1999 one paper by chiropractors investigated the benefits of phonophoresis. Gimblet et al , reported treating two subjects with calcific tendonitis by using soft tissue therapy, phonophoresis and manipulation. Both subjects at the end of the treatment protocol experienced complete resolution of symptoms.
Transverse friction massage has been advocated by a number of authors in the management of shoulder disorders [19,34]. Hammer describes friction massage as a technique where an involved muscle, tendon or ligament is massaged by applying pressure with a reinforced finger [19,34]. The transverse motion across the involved tissue and the resultant hyperaemia are said to be the chief healing factors of friction massage [19,34]. The transverse action is said to prevent the formation of scar tissue while longitudinal friction effects the transportation of blood and lymph .
The traumatic hyperaemia is postulated to release histamine and bradykinins resulting in vasodilation and reduction of oedema . Friction massage is said to stimulate the proliferation of fibroblasts and collagen fibre realignment with cross linkages .
It is reported that up to two weeks are required for mature cross-links to form . In the acute stage a light friction is suggested while in the chronic condition, a stronger pressure may be required . Hammer  also describes the successful management of a chronic bursitis by the use of soft tissue friction massage.
The management of the subjects in this paper also included orthopaedic, motion assessment and treatment of spinal structures including the cervical and thoracic spines. Diversified spinal adjustments were directed at the identified hypo mobile motion segments of the cervical and thoracic spines. This included assessment and adjustment of the glenohumeral joint in restricted planes of motion.
It is postulated that abnormal thoracic and cervical spine postural alignment (with any associated spinal joint fixation) may alter the resting position of the scapula contributing to problems of the rotator cuff musculature . In our cases changes in the lateral spinal curves were particularly noted in the third and fourth patients .
Abnormal spinal curves can result from chronic poor posture which may result in shoulder girdle muscle imbalance, altered muscle length tension relationships, joint incongruity, ligamentous laxity, changes in arthrokinematics and gross shoulder motion .
As noted by many clinicians a commonly related postural condition is that associated with anterior head carriage associated with rounded shoulders [19,23]. This type of postural deviation often causes a compensatory extension at the atlanto-occipital articulation, reversal or flattening of the cervical lordosis, thoracic kyphosis, protraction of the scapulae with the inferior angle of the scapula moving medially whilst the glenoid fossa moves anterior and inferior, and finally internal rotation of the humerus.
As a result, muscle imbalances of the shoulder girdle may occur. These potentially include parascapular muscle weakness, winging of the scapula, altered scapula position, and scapula dysrhythmia [10,23]. Also, weakness of the posterior rotator cuff muscles may influence the force couple mechanism at the glenohumeral joint causing a resultant upward shear of the humeral head during elevation of the arm.
During shoulder elevation the dominant force vector is provided by the deltoid muscle and in a superior direction. Under normal circumstances the cuff muscles will counter this superior shear in the opposite direction, creating a stabilizing and compressive action of the humeral head with respect to the glenoid during elevation. A diagrammatic representation of the gleno-humeral force couple  is seen in Figure 1. With cuff weakness (even slight) the force couple may be altered enabling an abnormal upward displacement of the humeral head and the impingement of the subacromial structures and the humeral head against the under surface of the acromion [10,23].
Repetition of this process may cause irritation of pain producing structures creating shoulder pain syndromes. In order to address the abnormal force couple and its potentially causative mechanism, specific exercises were introduced to help restore strength and muscular functioning of the glenohumeral joint and scapula articulations. (That is, once motion was normalised).
It is acknowledged that a significant weakness in this case series is the lack of imaging using diagnostic ultrasound to confirm the diagnosis of impingement or indeed some other cause for the pain. We encourage a further study of the treatment protocol described above. This study should be a randomised controlled trial and include diagnostic ultrasound confirmed impingement.
Successful management of rotator cuff impingement and related shoulder pain syndromes should include the consideration of potential sources of shoulder pain. Also the function of the implicated structures in global shoulder function should be reviewed. This should include the associated structures of the scapulohumeral, scapulothoracic articulations, the cervical and the thoracic spine.
This paper highlights a successful outcome for 4 subjects with clinically diagnosed shoulder impingement syndrome after receiving a multimodal treatment approach in a chiropractic setting.
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