Dr. Pgdm's Treatment Plan

On 9/23/16 I met with Mr. Russell at the Covenant Occupational Medicine. Mr. Russell said his pain level is at a 1 to 2 now. He is able to tolerate sitting, standing and walking more since starting physical therapy. He reports he is doing a home exercise program also. Dr. Eckstein said he would increase his work restrictions. He would like him to have 2 more weeks of physical therapy. He hopes at the next appointment to be released.

Treatment plan includes saliva toxicology, lumbar MRI with and without contrast and lumbar back brace to provide symptomatic relief for chronic low back pain and to reduce pain by restricting mobility of the trunk and to support the weak spinal muscles. Goal is to facilitate healing of the lumbar spine.

I spoke with Mr. Naranjo many times since the last reporting period regarding scheduling of occupational therapy and also the MRI. Once the MRI and x-ray were done he declined going back to Dr. Branch for a follow-up appointment on 1/31/8. He has requested to see his primary care doctor’s office.

Komblatt, the patient underwent extensive chiropractic treatment with 87 sessions from 10/07/11 through 07/11/12. It was opined that it does appear that the IW ha s undergone excessive passive-chiropractic treatment referable to both lumbar spine and right shoulder. It was further opined that the IW has reached MMI regarding the lumbosacral strain and contusion of the right shoulder within approximately 6-8 weeks post injury. Appropriate treatment would have consisted of aggressive right shoulder and low back rehabilitation to include aerobic conditioning, strengthening exercises involving the right upper extremity, lumbar spine and core, and resumption of normal recreational and work activities within 6-8

IW was diagnosed with sprain of the ligaments of the cervical spine. Patient has received chiropractic care. Response has been good and IW is encouraged with gains being made. Improved function and functional restoration are expected with additional treatments. Plan is for chiropractic treatment, 2 times a week for 3 weeks.

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

Based on the orthopedic consultation report dated 03/04/16 by Dr. Strudwick, the patient reports that his symptoms have returned and he has pain at night with elevation, pushing, pulling, reaching and heavy lifting at shoulder level and above.

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

Based on the latest follow-up evaluation progress report dated 03/02/16, the patient complains of right shoulder pain and stiffness. He states that his shoulder feels sore. He states that his pain is aggravated by the cold weather and over activity. The patient has not attended physical therapy for some time due to travel outside of the country. He is using an analgesic cream.

01/11/16 PT Evaluation Report documented that the patient is showing good progress towards goals, with a decrease in pain in the right lower leg, ankle and foot when ambulating. But the remaining impairments, including reduced strength, limited ROM and gait deviations cause poor ability to ambulate. Continue skilled PT is necessary in order to address the remaining deficits. Sort-term and long-term goals were discussed.

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.

AME dated 6/19/2012 future medicals recommends access to follow up visits for monitoring of his condition with continued provision of pharmacologic agents as prescribed by the managed by the designated primary treating physician. In the setting of symptom flare-ups, re-instatement of brief courses of traditional physical therapy/chiropractic treatment/acupuncture/massage therapy would be beneficial in restoring to baseline function, not anticipated to exceed the requirement of 10 to 14 sessions of all modalities combined per calendar year. Yearly

Dr. Lichtenberg recommended a treatment program including chiropractic adjustments, physical therapy. Mr. Rascon was prescriptions for Tramadol and Diazepam. He further indicated Mr. Rascon was no able to work at that time. Mr. Rascon was instructed to return for reevaluation in one week.

Diagnoses include the following: status post blunt head injury with loss of consciousness; posttraumatic cephalgia; cervical spine strain/sprain with radiculitis; thoracic spine strain/sprain; lumbosacral spine strain/sprain with radiculitis; status post left shoulder arthroscopic surgery dated 07/28/14; postsurgical left frozen shoulder and stiffness; left wrist pain secondary to cane use; bilateral knee strain; bilateral knee tendinosis, left knee degenerative joint disease, aggravated; sleep disturbance secondary to pain; and depression, situational. He is referred for follow-up with neurology.

Looking at the overall Functional Movement Screen the athlete has some dysfunction within certain movement patterns. Over the next few 6 weeks I will prescribe some corrective strategies for the athlete which will hopefully correct the movement. My corrective strategies will have categorized into 3 sections: