Patient's Case Summary

DOI: 5/5/2015. Patient is a 53-year-old male engineer who sustained injury while lifting a 10 inches long steel bracket when he felt a pull in his lower back.

MRI of the lumbar spine performed on 10/30/14 demonstrated mild anterolisthesis and prominent degenerative changes at L4-5, resulting in contact and possible impingement upon passing L5 nerve roots bilaterally. There is moderate bilateral facet arthropathy at this level. Mild central canal narrowing is seen at L4-5. Mild chronic compression deformity, superior endplate of T12 is seen.

DOI: 7/7/2015. The patient is a 48-year-old male cleaner who sustained a work-related injury to his back while moving a heavy bookcase. As per OMNI, the patient was diagnosed with lumbar degeneration, thoracic or lumbosacral neuritis and myofascial pain.

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

DOI: 6/23/2016. Patient is a 42-year-old female registered nurse who sustained injury to her neck/left shoulder when she twisted to keep the attachment from falling to the floor. Per OMNI, she was initially diagnosed with strain to multiple body parts.

11/13/14 MRI of the lumbar spine showed 4mm left paracentral and foraminal disc protrusion at L4-5, which mildly impinges upon the thecal sac and the proximal left L5 nerve root. The disc protrusion also moderately narrows the left foramen and lateral recess. There was also a 2mm posterior central disc protrusion at L5-S1. A 2mm disc bulge at L2-3 was seen. There was a mild degenerative facet and ligament flava hypertrophy at L4-5 and

MRI of the lumbar spine dated 07/30/15 demonstrated interval post-surgical change with removal of the disc extrusion at L4-5. There is residual granulation tissue versus broad-based left paracentral disc protrusion with left lateral recess stenosis.

It was noted that the patient has made significant gains in the HELP functional restoration program attaining his goals. He is still unable to return to work but is determined to do so. He is certainly not regressed in any way. He continues in a positive direction in his home exercise program despite occasional flares. He has made some medication reductions since he has left the

Goals of Treatment Plan include decreasing pain/spasms, increasing range of motion/ability to perform normal activities of daily living/strength, returning the patient to his pre-clinical status and increasing function. Long term goals include the reduced usage of over-the-counter/prescription medications as well as an increase in up to 5-10 repetitions of therapeutic exercise/neuromuscular education and an increase in 2-5 minutes of spinal endurance exercises (recumbent bike/ergometer) by the next

DOI: 05/26/2015. Patient is a 55-year-old male crew member who sustained an injury to his neck when a large mixing bowl fell on the right side of his head and ear. Per OMHI entry, he is diagnosed with neck sprain.

DOI: 7/18/1999. Patient is a 63-year-old male crew leader who sustained a work-related injury when he tripped over a mat at work. As per OMNI, the patient is status post left knee arthroscopy in 2001, knee replacement in 2004 and gastric bypass surgery in 5/2013.

DOI: 12/20/2010. Patient is a 63-year-old female compliance support specialist who sustained a work-related injury when she slipped and fell on wet tile floor. Per OMNI, she strained her left wrist, left shoulder and neck.

DOI: 1/29/2012. Patient is a 34-year-old female clinical assistant who sustained a work-related injury to her back when she was transferring a patient and felt pain in her low back and left side. She has prior history of lumbar laminectomy. She was treated conservatively with non-steroidal anti-inflammatory drugs, physical therapy and work restrictions. Per the PT progress notes dated 10/29/14, patient has attended 21 sessions for the back. She is status post left sacroiliac joint and left piriformis trigger point injection on 08/27/15.

DOI: 11/13/2014. Patient is a 32-year old male technician who sustained injury at the time he was breaking loose a pulser component, he felt a sharp pain to his right side, low back buttocks and right leg. The patient was subsequently diagnosed with lumbar degenerative disc disease, radiculopathy and, lumbar spinal stenosis. Per MRI of lumbar spine without contrast dated 12/23/14 revealed at L4-5 there is disc space height loss, disc bulging and facet degenerative change; at L5-S1 there is posterior disc bulging resulting in mild narrowing of the central canal, and; at T11 to T12 there is posterior disc bulging resulting in mild narrowing of the central canal. As per focused history and physical dated 3/17/15, patient is presented to the office