title: A multi-modal treatment approach for the shoulder: a 4 patient case series.
abstract: BACKGROUND
  This paper describes the clinical management of four cases of shoulder impingement syndrome using a conservative multimodal treatment approach.
  
  
  METHODS
  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.
authors.affiliation: Department of Health and Chiropractic, Macquarie University, 2109, Sydney, Australia. mariochiro@optusnet.com.au
authors.forename: Mario
authors.initials: M
authors.lastname: Pribicevic
authors.forename: Henry
authors.initials: H
authors.lastname: Pollard