Closed Head Injury

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Per AME report dated 05/11/15 by Dr. Pang, it was opined that the IW has reached MMI. Whole person impairment is 12 % for the thoracic spine and 17% to the lumbar spine. MD recommends provisions for the IW to seek medical attention for flare-ups or exacerbations with the possibility of undergoing PT, medications, further diagnostic imaging and

MRI of the cervical spine obtained on 06/26/13 showed mild degenerative spondylitic changes and status post posterior fusion.

Treatment plan includes follow-up with orthopedics, follow-up with psychology, Dr. Gandolfo for additional treatments for major depressive disorder, additional PT 2 x 3 sessions to treat the lumbar spine, additional PT for vestibular rehabilitation, follow-up with neurologist, referral for psychology and follow-up with primary care physician (PCP).

She reports tenderness to the posterior aspect of the cervical spine, trapezius region and scapular region with deep palpation.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Prognosis is guarded at this time since the patient is actively rehabbing and treatment is incomplete. The patient understands that chiropractic management through active and passive treatments have been demonstrated to be effective in the treatment of chronic spinal soft tissue injuries.

Even with active assistance, the patient can only achieve approximately 140 degrees of forward elevation, 60 degrees of external rotation, and internal rotation barely to his upper sacrurn. He has 4/5 supraspinatus weakness and pain. Internal and external rotation strength seems to be normal. He has a nonspecifically painful Neer’s, Hawkins, and O’Brien’s test. His proximal biceps and acromioclavicular (AC) joint are both very tender to palpation.

Head injuries (also known as traumatic brain injuries) have become one of the most dangerous and common injuries present in today’s society. Although most people generally associate head injuries directly to sports, that is not always the case. In fact, the majority of head injuries occur as a result of incidental falls, vehicle-related collisions, and accidents at home, work, and the outdoors. From a minor bump on the head, to a severe concussion, all injuries should be taken seriously in order to prevent further damage such as permanent disability, or even death.

DOI: 7/16/2002. The patient is a 61-year old male assistant store manager who sustained a work-related injury to his low back when he lifted a bucket of pain. As per OMNI entry, the patient was diagnosed with multi-level degenerative disc disease of the lumbar spine. As per medical report dated 6/13/16, the patient rates his pain with medications as 5 and 8 if without medications. Quality of sleep is fair. Activity level has remained the same. The patient is diagnosed with postlaminectomy syndrome, not elsewhere classified; spondylosis without myelopathy or radiculopathy lumbosacral region; other spondylosis with myelopathy, cervical region; other spondylosis with myelopathy, cervicothoracic region; and other spondylosis with myelopathy, site

Guidelines Utilized: According to the Official Disability Guidelines, The anticipated length of disability for the diagnosis Other spondylosis with radiculopathy lumbar region M47.26 is 16 to 32 days, Other spondylosis with radiculopathy lumbosacral region M47.27 is 16 to 32 days, Sacroiliitis M46.1 is 15 to 122 days, Sacrococcygeal disorders M53.3 is 28 to 116 days, Low back pain M54.5 is 17 to 50 days. Other intervertebral disc displacement, lumbar region M51.26 is 71 to 164 days. On 12/14/16 Chronic Pain Syndrome diagnosis was added projection for recovery is 124 to 365 days. On 6/29/17 Dr. Rampersaud added

12/04/15 Progress Report noted that the patient has chronic daily pain in the neck, which radiates into the arms with numbness and tingling. AROM of the cervical spine revealed that the patient is very guarded in the neck motion. The patient reported moderate pain on extremes of motion. Motor exam was normal in all muscle groups of the upper extremities. Sensory exam was normal. No pathologic reflexes were noted. The patient has full ROM in all major joints of the upper extremities. The patient has a disc herniation in the neck, which has been managed neurosurgically. The

DOI: 1/25/2016. Patient is a 59-year-old female sales representative who sustained injury when she bent over and strained her neck. Per OMNI entry, he was initially diagnosed with neck strain. Patient has completed 20 PT sessions.

Per the medical report dated 09/13/16 by Dr. Grimm, the patient complains of pain to his neck and low back, without radiation. There has been improvement since the last visit. He notes that the pain is worse with activity, and alleviated by home exercise program (HEP).