Physical Therapy: Chiropractic Summary

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

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12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather

Physical examination revealed that the patient’s back is less tender. There is facet tenderness over the bilateral L3-S1. There is also slight pain with limited rotation, flexion, and hyperextension. The right lower extremity is noted to be weaker. The lumbar spine examination is positive for seated straight-leg raise on the left and facet loading. As per treatment plan, the patient will be continuously evaluated for medication regimen and make alterations as necessary. It was noted that the patient states that there is continued need for his Zanaflex as necessary for flare-up of muscle spasms until he is able to start up chiropractor therapy again. He will try to discontinue the medication next month with chiropractor therapy. As per office notes dated 5/23/16, the patient’s pain level is 5-6/10. He states continued need for his Zanaflex as necessary for fare-up until he is able to start up chiropractic therapy. He continues to have neck pain with intermittent periods of sharp-stabbing pain over the right side with radiation to the bilateral upper extremities with numbness as well as associated cramping into upper extremity and into fingers. Current medications include Zanaflex, Nexium, Celebrex, and

Electrodiagnostic consultation report dated 10/02/15 revealed normal study of both upper limbs and cervical paraspinals. No evidence of cervical radiculopathy. No median or ulnar neuropathy.

August 03, 2015 – August 18, 2015 – Physical Therapy: Mr. Rascon presented to Movement Dynamics five (5) more times during this period. Mr. Rascon’s complaints where generalized and remained the same. He continued to have some functional limitations and still had. work restrictions including no heavy lifting. The objective findings, diagnosis and program recommendations were unchanged at this time.

The patient should stay active but avoid heavy lifting or physical work. Doctors will prescribe regular pain relievers to manage the disorder. Referral would be crucial to help in physical treatments, multidisciplinary and manipulation approaches, which should take place after every two weeks. The suitable multidisciplinary approaches include cognitive behavioral therapy, McKenzie exercises as well as chiropractic manipulative therapy and standard GP to decrease the pain and boost physical

Back, neck and joint pains are given instantaneous relief with chiropractic care. These pains are commonly a product of misalignments in the particular body parts. These

“Valentine has you back.” While Dr. Louis Valentine’s motto is certainly appropriate for his respected chiropractic care practice, it’s perhaps a little too simple for a practice offering such comprehensive neck and back pain relief. This Cincinnati doctor of chiropractic has been called “The Chiropractor the MD’s Trust,” high praise given with good reason. Every chiropractic adjustment you receive in Dr. Valentine’s office backed by over 20 years of experience, extensive firsthand research into chiropractic care, an impeccable scientific understand of the body, and genuine care for clients. His expertise is widely recognized, and his earned him the highest certification in Whiplash Biomechanics and Traumatology, an honor conferred by the Spine

no difficulties and showed no difficulty getting up from a chair. She did not use assistive devices or bracing materials. Full range of motion was recorded in the shoulder joints, elbows, wrists, hands, hips, knees, and ankles. Cervical spine rotation right and left was 80 degrees, with full flexion and extension. The straightaway walk was unremarkable as was the tandem step test, toe lift, heel walk, one-foot stand, and Romberg test. The claimant did not use any assistive devices. Dr. Keown diagnosed the claimant with chronic right shoulder pain, refractory bursitis, or a partial tear of the rotator cuff. She opined the claimant had the ability to sit six to eight hours, walk or stand six to eight hours, occasionally lift 35 to 40 pounds, frequently lift 10 to 15 pounds and would not require assistive devices (Ex. 7F).

01/26/16 Progress Report noted that the patient presented with left shoulder pain. The pain was gradual in onset and is constant. The pain is characterized as burning, sharp, shooting, and throbbing. It radiates to the neck. She described her pain as moderate to severe. Her condition is associated with numbness in her left fingertips and weakness in her upper extremities. Any activity, movement and reaching aggravate the pain. Stretching and hot showers relieve the pain. The level of sleep has been decreased due to difficulty falling asleep. The quality of sleep is poor. She has difficulty performing her ADLs. Current medications: Meloxicam, Naproxen, and Spironolactone. Review of Systems was positive for weakness and nausea. The patient also has anxiety and depression. She has had psychiatric, psychological, or social work evaluations or treatments for problems. The physical exam of the cervical spine revealed that the ROM is restricted. There were spasms and tenderness of the paravertebral muscles bilaterally. There was also spinous process tenderness noted on C6 and C7. Tenderness is noted at the paracervical muscles and trapezius. Spurling’s maneuver produces no pain in the neck muscles or radicular symptoms in the arm. Adson’s test is negative. No signs of meningism. Cervical facet loading is negative on both sides. The exam of the right shoulder was

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Spasm, tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. Wadell’s sign and Pelvic compression test is positive. There is spasm over the right sacroiliac joint and right L5-S1 and L4-5 facet joints. Kemp’s maneuver is positive bilaterally, right greater than the left. Right provocative facet maneuvers are

The exam revealed evidence of previous surgery of the right shoulder. There was significant atrophy compared to the left of the supraspinatus and infraspinatus muscles on the right. Cervical Spine: There was pain to palpation at C5-C6, C7 and paraspinal muscles on the right. The ROM was significantly reduced. Sensation is decreased in the C5-C6 dermatomal distribution in the right arm compared to the left. Reflexes are trace biceps, triceps, brachioradialis on the right to +1 biceps, triceps and brachioradialis on the