harper chelsea

8/3/2019 Harper Chelsea

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Re: Ms. Chelsea Harper - Visit Date: Friday, February 12, 2010

Ms. Harper presented herself at our office on February 12, 2010 for an initial examination and evaluation.

INJURY/ONSET DESCRIPTION:Ms. Harper stated that she was the driver in a car which was stopped at an intersection.

Ms. Harper also reported that, at the time of the accident, the road conditions were clean and dry and visibility wasgood. In addition, she stated the damage to her car was moderate. Damage to the other vehicle was moderate. She

also stated that she did see the accident coming and therefore was braced for the impact. Also, she was wearing her

seat belt and had her shoulder harness on. No front or side air bags deployed at the moment of impact. Her car was

equipped with headrests, her own headrest being even with the bottom of her head at the time of the accident. She

also noted that she had her head facing straight forward at the moment of impact. On impact the patient's body did

not strike the inside of her vehicle. She stated that she did not lose consciousness during the accident. According to

the patient, the police showed up at the scene. An accident report was filled out at that time.

INITIAL COMPLAINTS:Immediately following the accident, the patient's main complaints included pain behind her eyes, fatigue, ringing in

the ears, depression, tension, irritability, anxiety, stiffness in the neck, nervousness, headaches, nausea, pain in the

mid back, neck pain, dizziness and pain in the low back. Following the accident Ms. Harper drove herself home.The patient did not have x-rays taken following her injury. The patient had no lab work done following theaccident.

SUBJECTIVE COMPLAINTS:An assessment of Ms. Harper's current signs and symptoms was performed today. Her first symptom is dull, aching,

spastic, throbbing, numbing, cramping, pounding and constricting pain in the neck bilaterally. She reported that the

pain radiates into the head on the right side and both shoulders. It occurs between three fourths and all of the time

when she is awake, andprecludes carrying outactivities of daily living.

Ms. Harper's second stated symptom is dull, aching, throbbing and pounding frontal headaches. It occurs between

one half and three fourths of the time when she is awake, and causesserious diminution in her capacity to carry out

daily activities.

She stated her third symptom is aching, shooting, spastic, throbbing, burning, cramping, pounding and constrictingpain in the upper back bilaterally. It occurs between one half and three fourths of the time she is awake, and causes

serious diminution in her capacity to carry out daily activities.

ACTIVITIES OF DAILY LIVING ASSESSMENT:Based on an assessment of Ms. Harpers history, along with her subjective complaints, objective findings, and other

test results, it is evident from a standpoint of medical certainty, that her current condition did result from the type of

injury/onset described in this report. She reported suffering varying degrees of losses of functional capacity with the

following activities:

With regard to Self Care and Personal Hygiene, Ms. Harper stated: bathing, showering and washing her hair can be

virtually impossible to do at all, because of intense pain; washing her face, brushing her teeth, putting on her shoes,

tying her shoes, preparing meals, eating, cleaning dishes, taking out the trash, doing the laundry and going to thetoilet can be performed, despite significant pain, but only if she has help; drying her hair, combing her hair, making

her bed, putting on her shirt and putting on her pants can be managed by herself, despite marked pain.

With regard toPhysical Activity, Ms. Harper stated: sitting, reclining, walking, stooping, sitting continuously and

kneeling can be virtually impossible, because of extreme pain; standing, bending backward, bending to the left,

bending to the right, walking for long periods, twisting to the left, twisting to the right, leaning forward, leaning

backwards, leaning to the left, leaning to the right and kneeling for long periods can be done, despite significantpain, but only with help; standing for long periods, squatting, reaching and bending forward can be managed alone,

despite marked pain.


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RegardingFunctional Activities , Ms. Harper stated: carrying small objects, carrying a brief case, climbing stairs,

climbing up any type of incline, exercising her lower body and exercising her legs can be virtually impossible to do

at all, because of intense pain; carrying large purses, pushing things while seated, pushing things while standing,

pulling things while seated, pulling things while standing and exercising her arms can be performed, despitesignificant pain, but only if she has help; carrying large objects, lifting weights off the floor, lifting weights off of a

table and exercising her upper body can be managed by herself, despite marked pain.

With regard to Social and Recreational Activities, she stated: bowling, golfing, jogging, dancing, swimming, skiing,

ice skating, roller skating, participating in competitive sports, participating in hobbies and dining out can be virtually

impossible, because of extreme pain; dating can be managed alone, despite marked pain.

Regarding Travel, Ms. Harper stated: driving a motor vehicle, riding as a passenger in a motor vehicle, riding onairplanes and riding on trains can be performed, despite significant pain, but only if she has help; driving for long

periods of time and riding as a passenger for long periods can be managed by herself, despite marked pain.

With regard to Communication, Ms. Harper reported the following: her ability to concentrate, hear, listen, speak

and write are prevented by her condition; her ability to read and use a computer or typewriter are moderately

restricted by her condition.

With regard to Sensory Functions, she stated the following: her sight, hearing, sense of touch, sense of taste andsense of smell are completely precluded by her condition.

With regard toHand Functions, Ms. Harper reported the following: her ability to grasp things, hold onto things,

pinch things with her fingers, perform percussive hand movements and discriminate things by touch are extremely

limited by her condition.

Regarding Sleeping, she stated: her ability to sleep a normal, restful nights sleep is moderately restricted by her

condition.

With regard to Sexual Function, she stated: her ability to participate in desired sexual activity is moderatelyrestricted by her condition.

GENERAL PHYSICAL EXAMINATION:Ms. Harper is a mentally alert and cooperative female.

Her superficial appearance suggested she was in distress. Minor's Sign was not present, tending to rule out sciatica.

An antalgic spine tilt on the right side was apparent when she stood upright. Gait: On ambulation, she revealed an

antalgic gait, apparently favoring the left side.

Stature: Corpulent.

Heart: No arrhythmia or murmurs were noted. Lungs: No rales, rhonchus or wheezing were noted in any of the

lobes of the lungs. On examination, the eyes, ears and throat appeared normal.

OBJECTIVE EVALUATION:Deep Tendon Reflexes: An examination of the deep tendon reflexes of the upper and lower extremities was

performed in relation to the cervical and lumbar nerve roots, which showed them reacting within normal limits with

approximately equal strength, one side being compared to the other.

Range of Motion Studies: The following is an evaluation of the patient's present condition with regard to spinal

joint motion. Cervical Spine: Flexion: 30 degrees (norm = 50), with pain and spasm. Extension: 15 degrees (norm

= 60), with pain and spasm. Left lateral flexion: 15 degrees (norm = 45), with pain and spasm. Right lateral flexion:

20 degrees (norm = 45), with pain and spasm. Left rotation: 45 degrees (norm = 80), with pain and spasm. Right

rotation: 40 degrees (norm = 80), with pain and spasm. Thoracic Spine: Extension: 0 degrees (norm = 0-59), with


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pain and spasm. Flexion: 35 degrees (norm = 50), with pain and spasm. Left rotation: 30 degrees (norm = 30), with

pain and spasm. Right rotation: 30 degrees (norm = 30), with pain and spasm.

Upper Extremities: Left Shoulder: The left strong (Grade 5). The weak (Grade 4). The very weak (Grade 3). Right

Shoulder: The right strong (Grade 5). The weak (Grade 4). The very weak (Grade 3). Lower Extremities: LeftHip: The left strong (Grade 5). The weak (Grade 4). The very weak (Grade 3). Right Hip: The right strong (Grade

5). The weak (Grade 4). The very weak (Grade 3). Left Knee: The left strong (Grade 5). The very weak (Grade 3).Right Knee: The right strong (Grade 5). The very weak (Grade 3). Left Ankle: The left strong (Grade 5). Right

Ankle: The right strong (Grade 5).

Orthopedic Tests: Standing Tests: Trendelenburg's Test was negative. Valsalva Maneuver was negative.

Sitting Tests: The Maximum Cervical Compression Test was positive bilaterally. The Shoulder Compression

Test was positive bilaterally. The Shoulder Depression Test was positive bilaterally. Supine Tests: Soto-Hall

Test was positive, with the patients pain being localized at C4-C7.

Palpation Evaluation: Paraspinal Studies: Palpation of the left suboccipital muscle group of the neck demonstrated

mild muscle spasms, and slight pain and tenderness. In the neck, palpation of the inion (base of the occiput-midline)

demonstrated moderate pain. The right suboccipital muscle group of the neck revealed mild muscle spasms, and

moderate pain. Palpating the left paracervical muscles revealed mild muscle spasms, moderate pain, and tender

trigger points. The right paracervical muscles demonstrated mild muscle spasms, tender trigger points, and

moderate pain. Palpation of the left upper thoracic group of the dorsum disclosed moderate muscle spasms, andmoderate pain. The upper thoracic midline structures of the dorsum demonstrated articular fixations, and severe

pain. The right upper thoracic group of the dorsum revealed mild muscle spasms, tender trigger points, andmoderate pain. Palpation of the left mid thoracic group disclosed severe pain, malpositions, mild muscle spasms,

and tender trigger points. The mid thoracic midline structures demonstrated articular fixations, and severe pain.

The right mid thoracic group revealed malpositions, and moderate pain. Palpation of the left thoracolumbar group

disclosed severe pain, mild muscle spasms, and active trigger points. The thoracolumbar midline structures

demonstrated articular fixations. The right thoracolumbar group revealed severe pain, mild muscle spasms, and

active trigger points. Palpating the left iliolumbar group of the low back disclosed mild muscle spasms. The

iliolumbar midline structures of the low back demonstrated articular fixations. The right iliolumbar group of the low

back revealed mild muscle spasms, and moderate pain. Palpation of the coccyx revealed that pain response andtissue consistency were within normal limits. Trigger Point Studies: The left trapezius muscle group disclosed

severe pain. The right trapezius muscle group elicited severe pain. The left rhomboid muscle group revealed severe

pain. The right rhomboid muscle group disclosed severe pain. Palpating the left mid scapular muscles revealed avocalized, sharp pain response. The right mid scapular muscles disclosed severe pain. The left gluteal muscle group

revealed slight pain and tenderness. The right gluteal muscle group disclosed slight pain and tenderness.

Abdominal Regions: Using firm digital pressure, the peritoneum was deflected in order to perform a deep tissue

examination of the abdominal region. Palpation of the upper quadrants revealed no abnormal pain response with

normal tissue consistency. Palpating the lower quadrants revealed normal tissue consistency and there was noabnormal pain response.

ASSESSMENT/TREATMENT:Today's Modalities & Procedures: Following were the modalities used and/or recommended today: cervical

traction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the accident,Ms. Harper was instructed to apply alternating hot and cold compresses to the injured area.

Treatment to date has been for the purpose of reducing symptoms and providing for maximum regrowth andrecovery.

Treatment to date has been of a conservative nature, consisting of a regimen of mild spinal manipulation and

physiotherapy.

Ms. Harper was referred to my office for the following treatment:

Chiropractic adjustments


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Cervical traction

Corrective spinal exercises

Ice (cryo) therapy

Intersegmental mobilization

Chiropractic manipulationsTherapeutic massage

Resistive exercisesThe above was for the purpose of decreasing pain, decreasing swelling and inflammation, decreasing spasms,

increasing range of motion, increasing strength, increasing function, retarding degeneration and stabilizing

segments.

Today's Assessment: Favorable results are expected for this patient. Traumatic insult to the cervical spine with

resultant brachial radiculopathy.

Cervical sprain/strain, with attendant radiculopathy resulting in motor weakness of the cervical extensor muscles.

Traumatically induced sprain/strain of the cervical spine, with attendant radicular syndrome.

Thoracolumbar sprain/strain resulting in intervertebral spinal motor unit disrelationships.

Prognosis: The prognosis for Ms. Harper is good at this time. Hers is a somewhat complicated case and despite thepossibility of permanent residuals, continued improvement is expected.

FUTURE CARE PLAN:Present Care Phase: As of today's visit, Ms. Harper is in a relief phase of care.

Future Treatment Plan: Ms. Harper's future care plan includes home exercises, cryotherapy, long axis traction,

intersegmental mobilization, chiropractic adjustments and resistive exercises two times a week.

Goals of Treatment Plan: The above treatment plan has the goal of decreasing pain, decreasing swelling and

inflammation, decreasing spasms, increasing strength, stabilizing segments, correcting muscle imbalance and

increasing flexibility.


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Re: Ms. Chelsea Harper - Visit Date: Monday, February 15, 2010

On February 15, 2010, Ms. Harper came to our office for treatment.

SUBJECTIVE COMPLAINTS:

An assessment of Ms. Harper's current signs and symptoms was performed today. Her neck pain hasn't changedsince her last visit with us. It's effect is felt between 76% and all of the time she is awake. This symptom presently

prevents certain activities of daily living. She stated that her frontal headache complaint also hasn't changed since

last visit. It's experienced between 51% and 75% of the time she is awake. Her daily activities are seriously

affected by this symptom. Ms. Harper's upper back pain is unchanged as well. It bothers her between 51% and 75%

of the time she is awake. Her daily activities are presently seriously affected by this symptom.

The objective findings that follow are virtually unchanged from the patient's last exam:

OBJECTIVE EVALUATION:Range of Motion Studies: Ms. Harper's spinal joint range of motion was checked again today: Cervical Spine:

Flexion: 30 degrees (norm = 50), with pain and spasm. Extension: 15 degrees (norm = 60), with pain and spasm.

Left lateral flexion: 15 degrees (norm = 45), with pain and spasm. Right lateral flexion: 20 degrees (norm = 45),

with pain and spasm. Left rotation: 45 degrees (norm = 80), with pain and spasm. Right rotation: 40 degrees (norm

= 80), with pain and spasm. Thoracic Spine: Extension: 0 degrees (norm = 0-59), with pain and spasm. Flexion: 35degrees (norm = 50), with pain and spasm. Left rotation: 30 degrees (norm = 30), with pain and spasm. Rightrotation: 30 degrees (norm = 30), with pain and spasm.

Kinesiological Studies: To determine if there were any nerve related motor impairments, the following muscles

were tested . This evaluation was based on the 5 to 0 scale, with 5 being normal. Upper Extremities: Left

Shoulder: The left Serratus Anterior and Deltoid (Anterior Division) were strong (Grade 5). The Rhomboid muscle

group, Levator Scapulae, Latissimus Dorsi, Supraspinatus, Infraspinatus, Teres Minor, Deltoid (Middle Division)

and Subscapularis were weak (Grade 4). The Deltoid (Posterior Division), Pectoralis Major and Pectoralis Minor

were very weak (Grade 3). Right Shoulder: The right Rhomboid muscle group, Serratus Anterior, Latissimus Dorsi,Infraspinatus, Deltoid (Middle Division) and Subscapularis were weak (Grade 4). The Levator Scapulae,

Supraspinatus, Teres Minor, Deltoid (Posterior Division), Pectoralis Major, Pectoralis Minor and Deltoid (Anterior

Division) were very weak (Grade 3). Lower Extremities: Left Hip: The left Sartorius, Gluteus Medius and

Minimus group, Tensor Fasciae Latae, Gracilis, Gluteus Maximus and Psoas Major were weak (Grade 4). The

Psoas Major and Iliacus group and Adductor muscle group were very weak (Grade 3). Right Hip: The right Gluteus

Medius and Minimus group was weak (Grade 4). The Psoas Major and Iliacus group, Sartorius, Tensor Fasciae

Latae, Adductor muscle group, Gracilis, Gluteus Maximus and Psoas Major were very weak (Grade 3). Left Knee:

The left Quadricep muscle group and Hamstring muscle group were weak (Grade 4). Right Knee: The rightQuadricep muscle group and Hamstring muscle group were weak (Grade 4).

Orthopedic Tests: Standing Tests: Trendelenburg's Test was positive bilaterally. Sitting Tests: Georges Test

was negative. The Maximum Cervical Compression Test was positive on the right side. The Shoulder

Compression Test was positive bilaterally. Supine Tests: Soto-Hall Test was positive, with the patients pain

being localized at C4-C7.


severe pain, mild muscle spasms, and tender trigger points. In the neck, palpation of the inion (base of the occiput-

midline) demonstrated articular fixations, and severe pain. The right suboccipital muscle group of the neck revealedmild muscle spasms, moderate pain, and tender trigger points. Palpating the left paracervical muscles revealed

severe pain, mild muscle spasms, and tender trigger points. The midline structures (spinous process tips and nuchal

ligament from C1 through C7) of the paracervical muscles disclosed articular fixations, and moderate pain. The

right paracervical muscles demonstrated moderate muscle spasms, tender trigger points, and moderate pain.

Palpation of the left upper thoracic group of the dorsum disclosed malpositions, moderate muscle spasms, active

trigger points, and severe pain. The upper thoracic midline structures of the dorsum demonstrated articular

fixations. The right upper thoracic group of the dorsum revealed malpositions, moderate muscle spasms, and active

trigger points. Palpation of the left mid thoracic group disclosed malpositions, moderate muscle spasms, active


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trigger points, and severe pain. The mid thoracic midline structures demonstrated articular fixations, and severe

pain. The right mid thoracic group revealed malpositions, mild muscle spasms, and active trigger points. Palpation

of the left thoracolumbar group disclosed mild muscle spasms, and moderate pain. The thoracolumbar midline

structures demonstrated articular fixations. The right thoracolumbar group revealed mild muscle spasms, and tender

trigger points.

ASSESSMENT/TREATMENT:The following continues to be the modalities performed on Ms. Harper:Today's Modalities & Procedures: These were the procedures that were performed and/or recommended today:

cervical traction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the

accident, Ms. Harper was instructed to apply alternating hot and cold compresses to the injured area.

Treatment to date has been for the purpose of reducing symptoms and providing for maximum regrowth and

recovery.

Treatment to date has been of a conservative nature, consisting of a regimen of mild spinal manipulation andphysiotherapy.



Cervical traction


Ice (cryo) therapy



Resistive exercises

The above was for the purpose of decreasing pain, decreasing swelling and inflammation, decreasing spasms,


segments.

Today's Assessment: Traumatic insult to the cervical spine with resultant brachial radiculopathy.




Prognosis: The prognosis for Ms. Harper is good at this time. Hers is a somewhat complicated case and despite the

possibility of permanent residuals, continued improvement is expected.

FUTURE CARE PLAN:The following continues to be the plan for Ms. Harper's future treatment:Present Care Phase: Currently, we have the patient in a relief phase of care.

Future Treatment Plan: Our future care recommendations include home exercises, cryotherapy, long axis traction,






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Re: Ms. Chelsea Harper - Visit Date: Thursday, February 18, 2010

The patient named above came to our office on February 18, 2010 for treatment.


Ms. Harper's current signs and symptoms were assessed today. Her neck pain has affected her as follows: It's effectis felt between 76% and all of the time she is awake. Some of her daily activities are currently being prevented bythis symptom. The patient's frontal headache complaint has been affecting the patient as follows: It's experienced

between 51% and 75% of the time she is awake. Her daily activities are seriously affected by this symptom. Her

upper back pain has had the following affect: It bothers her between 51% and 75% of the time she is awake.

Presently, the patient's daily activities are seriously being affected by this symptom.

OBJECTIVE EVALUATION:Range of Motion Studies: In order to evaluate the patient's present condition with regard to spinal joint motion,

she was examined with the following results: Cervical Spine: Flexion: 30 degrees (norm = 50), with pain and

spasm. Extension: 15 degrees (norm = 60), with pain and spasm. Left lateral flexion: 15 degrees (norm = 45), with

pain and spasm. Right lateral flexion: 20 degrees (norm = 45), with pain and spasm. Left rotation: 45 degrees

(norm = 80), with pain and spasm. Right rotation: 40 degrees (norm = 80), with pain and spasm. Thoracic Spine:

Extension: 0 degrees (norm = 0-59), with pain and spasm. Flexion: 35 degrees (norm = 50), with pain and spasm.Left rotation: 30 degrees (norm = 30), with pain and spasm. Right rotation: 30 degrees (norm = 30), with pain andspasm.

Kinesiological Studies: To determine if there were any nerve related motor impairments, the following muscles

were tested . This evaluation was based on the 5 to 0 scale, with 5 being normal. Upper Extremities: Left

Shoulder: The left Serratus Anterior and Deltoid (Anterior Division) were strong (Grade 5). The Rhomboid muscle

group, Levator Scapulae, Latissimus Dorsi, Supraspinatus, Infraspinatus, Teres Minor, Deltoid (Middle Division)

and Subscapularis were weak (Grade 4). The Deltoid (Posterior Division), Pectoralis Major and Pectoralis Minor

were very weak (Grade 3). Right Shoulder: The right Rhomboid muscle group, Serratus Anterior, Latissimus Dorsi,Infraspinatus, Deltoid (Middle Division) and Subscapularis were weak (Grade 4). The Levator Scapulae,

Supraspinatus, Teres Minor, Deltoid (Posterior Division), Pectoralis Major, Pectoralis Minor and Deltoid (Anterior

Division) were very weak (Grade 3). Lower Extremities: Left Hip: The left Sartorius, Gluteus Medius and

Minimus group, Tensor Fasciae Latae, Gracilis, Gluteus Maximus and Psoas Major were weak (Grade 4). The

Psoas Major and Iliacus group and Adductor muscle group were very weak (Grade 3). Right Hip: The right Gluteus

Medius and Minimus group was weak (Grade 4). The Psoas Major and Iliacus group, Sartorius, Tensor Fasciae

Latae, Adductor muscle group, Gracilis, Gluteus Maximus and Psoas Major were very weak (Grade 3). Left Knee:

The left Quadricep muscle group and Hamstring muscle group were weak (Grade 4). Right Knee: The rightQuadricep muscle group and Hamstring muscle group were weak (Grade 4).







midline) demonstrated articular fixations, and severe pain. The right suboccipital muscle group of the neck revealedmild muscle spasms, moderate pain, and tender trigger points. Palpating the left paracervical muscles revealed









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trigger points.

ASSESSMENT/TREATMENT:Today's Modalities & Procedures: Following were the modalities used and/or recommended today: cervicaltraction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the accident,

Ms. Harper was instructed to apply alternating hot and cold compresses to the injured area.


recovery.


physiotherapy.



Cervical traction


Ice (cryo) therapy


Chiropractic manipulations

Therapeutic massageResistive exercises



segments.





Prognosis: At this time, Ms. Harper's prognosis is good. Her case is somewhat complicated, but continued

improvement is expected, despite permanent residuals being a possibility.

FUTURE CARE PLAN:The following plan remains virtually unchanged since Ms. Harper's last visit:

Present Care Phase: Ms. Harper is presently in a relief phase of care.

Future Treatment Plan: Ms. Harper's future care plan includes home exercises, cryotherapy, long axis traction,intersegmental mobilization, chiropractic adjustments and resistive exercises two times a week.





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Re: Ms. Chelsea Harper - Visit Date: Monday, March 15, 2010

Ms. Harper presented herself at our office on March 15, 2010 for treatment.


Ms. Harper's current signs and symptoms were assessed today. Her neck pain was 6 on the 1 to 10 Pain Scale. It'seffect is felt between 76% and all of the time she is awake. This symptom presently prevents certain activities ofdaily living. She stated that her frontal headache complaint was 4 today, on the 1 to 10 Pain Scale. It's experienced

between 51% and 75% of the time she is awake. Her daily activities are seriously affected by this symptom. Her

upper back pain was 8 today, on the 1 to 10 scale. It bothers her between 51% and 75% of the time she is awake.

Presently, the patient's daily activities are seriously being affected by this symptom. Pt tried to work it out using

stretching, and core strengthening exercises, which at this time made things worse. Has returned for continuation of

treatment after 3 weeks of absence

The following objective findings have not changed since Ms. Harper's last exam:

OBJECTIVE EVALUATION:Range of Motion Studies: Ms. Harper's spinal joint range of motion was evaluated again today: Cervical Spine:

Flexion: 30 degrees (norm = 50), with pain and spasm. Extension: 15 degrees (norm = 60), with pain and spasm.

Left lateral flexion: 15 degrees (norm = 45), with pain and spasm. Right lateral flexion: 20 degrees (norm = 45),with pain and spasm. Left rotation: 45 degrees (norm = 80), with pain and spasm. Right rotation: 40 degrees (norm= 80), with pain and spasm. Thoracic Spine: Extension: 0 degrees (norm = 0-59), with pain and spasm. Flexion: 35

degrees (norm = 50), with pain and spasm. Left rotation: 30 degrees (norm = 30), with pain and spasm. Right

rotation: 30 degrees (norm = 30), with pain and spasm.

Kinesiological Studies: The following muscles were re-tested to determine if the nerve related impairments found

during the last exam were still present: Upper Extremities: Left Shoulder: The left Serratus Anterior and Deltoid

(Anterior Division) were still strong (Grade 5). The Rhomboid muscle group, Levator Scapulae, Latissimus Dorsi,

Supraspinatus, Infraspinatus, Teres Minor, Deltoid (Middle Division) and Subscapularis were still weak (Grade 4).The Deltoid (Posterior Division), Pectoralis Major and Pectoralis Minor were still very weak (Grade 3). Right

Shoulder: The right Rhomboid muscle group, Serratus Anterior, Latissimus Dorsi, Infraspinatus, Deltoid (Middle

Division) and Subscapularis were still weak (Grade 4). The Levator Scapulae, Supraspinatus, Teres Minor, Deltoid

(Posterior Division), Pectoralis Major, Pectoralis Minor and Deltoid (Anterior Division) were still very weak (Grade

3). Lower Extremities: Left Hip: The left Sartorius, Gluteus Medius and Minimus group, Tensor Fasciae Latae,

Gracilis, Gluteus Maximus and Psoas Major were still weak (Grade 4). The Psoas Major and Iliacus group and

Adductor muscle group were still very weak (Grade 3). Right Hip: The right Gluteus Medius and Minimus group

was still weak (Grade 4). The Psoas Major and Iliacus group, Sartorius, Tensor Fasciae Latae, Adductor musclegroup, Gracilis, Gluteus Maximus and Psoas Major were still very weak (Grade 3). Left Knee: The left Quadricep

muscle group and Hamstring muscle group were still weak (Grade 4). Right Knee: The right Quadricep musclegroup and Hamstring muscle group were still weak (Grade 4).

Orthopedic Tests: Standing Tests: Trendelenburg's Test was still positive bilaterally. Sitting Tests: Georges

Test was still negative. The Maximum Cervical Compression Test was still positive on the right side. The

Shoulder Compression Test was still positive bilaterally. Supine Tests: Soto-Hall Test was still positive, with the

patients pain being localized at C4-C7.

Palpation Evaluation: Paraspinal Studies: Palpation of the left suboccipital muscle group of the neck stilldemonstrated severe pain, mild muscle spasms, and tender trigger points. In the neck, palpation of the inion (base of

the occiput-midline) still demonstrated articular fixations, and severe pain. The right suboccipital muscle group of

the neck still revealed mild muscle spasms, moderate pain, and tender trigger points. Palpating the left paracervical

muscles still revealed severe pain, mild muscle spasms, and tender trigger points. The midline structures (spinous

process tips and nuchal ligament from C1 through C7) of the paracervical muscles still disclosed articular fixations,

and moderate pain. The right paracervical muscles still demonstrated moderate muscle spasms, tender trigger

points, and moderate pain. Palpation of the left upper thoracic group of the dorsum still disclosed malpositions,

moderate muscle spasms, active trigger points, and severe pain. The upper thoracic midline structures of the dorsum


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still demonstrated articular fixations. The right upper thoracic group of the dorsum still revealed malpositions,

moderate muscle spasms, and active trigger points. Palpation of the left mid thoracic group still disclosed

malpositions, moderate muscle spasms, active trigger points, and severe pain. The mid thoracic midline structures

still demonstrated articular fixations, and severe pain. The right mid thoracic group still revealed malpositions, mild

muscle spasms, and active trigger points. Palpation of the left thoracolumbar group still disclosed mild musclespasms, and moderate pain. The thoracolumbar midline structures still demonstrated articular fixations. The right

thoracolumbar group still revealed mild muscle spasms, and tender trigger points.


cervical traction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the



recovery.




Cervical traction


Ice (cryo) therapyIntersegmental mobilization


Therapeutic massage

Resistive exercises



segments.







FUTURE CARE PLAN:What follows continues to be the plan for Ms. Harper's future care:Present Care Phase: Presently, Ms. Harper is in a relief phase of care.

Future Treatment Plan: Our recommended future care plan for this patient consists of home exercises,

cryotherapy, long axis traction, intersegmental mobilization, chiropractic adjustments and resistive exercises two

times a week.

Goals of Treatment Plan: The goals intended to be achieved with the preceding treatment plan are decreasing

pain, decreasing swelling and inflammation, decreasing spasms, increasing strength, stabilizing segments, correcting


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muscle imbalance and increasing flexibility.


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Re: Ms. Chelsea Harper - Visit Date: Thursday, April 15, 2010

On April 15, 2010, Ms. Harper came to our office for treatment.


Ms. Harper's current signs and symptoms were assessed today. Her neck pain hasn't changed since her last visitwith us and is still at 6 on the Pain Scale. It's effect is felt between 76% and all of the time she is awake. Some ofher daily activities are currently being prevented by this symptom. The patient's frontal headache complaint also is

unchanged and is still at 4 on the Pain Scale. It's experienced between 51% and 75% of the time she is awake. This

symptom is seriously affecting her daily activities. Her upper back pain is unchanged as well and it is still at 8 on

the Pain Scale. It bothers her between 51% and 75% of the time she is awake. Presently, the patient's daily

activities are seriously being affected by this symptom. Pt remarked that she was struggling with relationship

issues, as well as work and financial wories that kept her from continuing care on the proper regiment.

OBJECTIVE EVALUATION:Range of Motion Studies: In order to evaluate the patient's present condition with regard to spinal joint motion,



pain and spasm. Right lateral flexion: 20 degrees (norm = 45), with pain and spasm. Left rotation: 45 degrees(norm = 80), with pain and spasm. Right rotation: 40 degrees (norm = 80), with pain and spasm. Thoracic Spine:Extension: 0 degrees (norm = 0-59), with pain and spasm. Flexion: 35 degrees (norm = 50), with pain and spasm.

Left rotation: 30 degrees (norm = 30), with pain and spasm. Right rotation: 30 degrees (norm = 30), with pain and

spasm.

Kinesiological Studies: Testing of the following muscles, using the 5 to 0 strength rating scale, was performed to

determine if there were any nerve related motor impairments. Upper Extremities: Left Shoulder: The left Serratus

Anterior and Deltoid (Anterior Division) were strong (Grade 5). The Rhomboid muscle group, Levator Scapulae,

Latissimus Dorsi, Supraspinatus, Infraspinatus, Teres Minor, Deltoid (Middle Division) and Subscapularis wereweak (Grade 4). The Deltoid (Posterior Division), Pectoralis Major and Pectoralis Minor were very weak (Grade 3).

Right Shoulder: The right Rhomboid muscle group, Serratus Anterior, Latissimus Dorsi, Infraspinatus, Deltoid

(Middle Division) and Subscapularis were weak (Grade 4). The Levator Scapulae, Supraspinatus, Teres Minor,

Deltoid (Posterior Division), Pectoralis Major, Pectoralis Minor and Deltoid (Anterior Division) were very weak

(Grade 3). Lower Extremities: Left Hip: The left Sartorius, Gluteus Medius and Minimus group, Tensor Fasciae

Latae, Gracilis, Gluteus Maximus and Psoas Major were weak (Grade 4). The Psoas Major and Iliacus group and

Adductor muscle group were very weak (Grade 3). Right Hip: The right Gluteus Medius and Minimus group was

weak (Grade 4). The Psoas Major and Iliacus group, Sartorius, Tensor Fasciae Latae, Adductor muscle group,Gracilis, Gluteus Maximus and Psoas Major were very weak (Grade 3). Left Knee: The left Quadricep muscle

group and Hamstring muscle group were weak (Grade 4). Right Knee: The right Quadricep muscle group andHamstring muscle group were weak (Grade 4).





Palpation Evaluation: Paraspinal Studies: Palpation of the left suboccipital muscle group of the neck demonstratedsevere pain, mild muscle spasms, and tender trigger points. In the neck, palpation of the inion (base of the occiput-

midline) demonstrated articular fixations, and severe pain. The right suboccipital muscle group of the neck revealed

mild muscle spasms, moderate pain, and tender trigger points. Palpating the left paracervical muscles revealed







13/49





of the left thoracolumbar group disclosed mild muscle spasms, and moderate pain. The thoracolumbar midlinestructures demonstrated articular fixations. The right thoracolumbar group revealed mild muscle spasms, and tender

trigger points.

ASSESSMENT/TREATMENT:The following modalities, which were also performed on Ms. Harper's last visit, were repeated today:Today's Modalities & Procedures: Following were the modalities used and/or recommended today: cervical

traction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the accident,



recovery.




Cervical traction


Ice (cryo) therapyIntersegmental mobilization


Therapeutic massage

Resistive exercises



segments.







FUTURE CARE PLAN:What follows continues to be the plan for Ms. Harper's future care:Present Care Phase: Currently, we have the patient in a relief phase of care.



times a week.




14/49



15/49

Re: Ms. Chelsea Harper - Visit Date: Monday, April 19, 2010

Ms. Harper presented herself at our office on April 19, 2010 for treatment.


An assessment was performed on Ms. Harper to determine her current signs and symptoms. Her neck pain hasslightly improved since her last visit. It was 6 on the 1 to 10 Pain Scale. It bothers the patient between 51% and75% of the time she is awake. This symptom presently prevents certain activities of daily living. She stated that her

frontal headache complaint was 4 today, on the 1 to 10 Pain Scale. It's experienced between 51% and 75% of the

time she is awake. Her daily activities are seriously affected by this symptom. Ms. Harper's upper back pain was 8

today, on the 1 to 10 scale. It bothers her between 51% and 75% of the time she is awake. Presently, the patient's

daily activities are seriously being affected by this symptom.

OBJECTIVE EVALUATION:Cranial Nerve Exam: A Cranial Nerve examination found them all to be within normal limits. Sensory Deficit

Testing: All upper and lower dermatomes were found to be within normal limits, with no loss of sensibility,

abnormal sensation, or pain noted. Postural Evaluation: The patient's spine, extremities, gait, etc., were

thoroughly inspected visually revealing anomalies which included cervical muscle tension bilaterally, a high

shoulder on the left, thoracic muscle tension bilaterally, lumbar muscle tension bilaterally, a neck curvature to theleft, cervical hypolordosis, a thoracic curvature to the right and walking in a stiff/guarded manner.

Range of Motion Studies: The patient's range of motion capacity was examined to evaluate her present condition

with regard to spinal joint motion: Cervical Spine: Flexion: 30 degrees (norm = 50), with pain and spasm.

Extension: 15 degrees (norm = 60), with pain and spasm. Left lateral flexion: 15 degrees (norm = 45), with pain and

spasm. Right lateral flexion: 20 degrees (norm = 45), with pain and spasm. Left rotation: 45 degrees (norm = 80),

with pain and spasm. Right rotation: 40 degrees (norm = 80), with pain and spasm. Thoracic Spine: Extension: 0

degrees (norm = 0-59), with pain and spasm. Flexion: 35 degrees (norm = 50), with pain and spasm. Left rotation:

30 degrees (norm = 30), with pain and spasm. Right rotation: 30 degrees (norm = 30), with pain and spasm.


determine if there were any nerve related motor impairments. Upper Extremities: Left Shoulder: The left

Rhomboid muscle group, Levator Scapulae, Serratus Anterior, Latissimus Dorsi, Supraspinatus, Infraspinatus, Teres

Minor and Deltoid (Anterior Division) were strong (Grade 5). The Pectoralis Major, Deltoid (Middle Division) and

Subscapularis were weak (Grade 4). The Deltoid (Posterior Division) and Pectoralis Minor were very weak (Grade

3). Right Shoulder: The right Rhomboid muscle group, Latissimus Dorsi and Infraspinatus were strong (Grade 5).

The Levator Scapulae, Serratus Anterior, Teres Minor, Deltoid (Posterior Division), Deltoid (Middle Division) andSubscapularis were weak (Grade 4). The Supraspinatus, Pectoralis Major, Pectoralis Minor and Deltoid (Anterior

Division) were very weak (Grade 3). Lower Extremities: Left Hip: The left Sartorius, Gluteus Medius andMinimus group, Tensor Fasciae Latae, Adductor muscle group, Gracilis and Gluteus Maximus were strong (Grade

5). The Psoas Major and Iliacus group and Psoas Major were weak (Grade 4). Right Hip: The right Psoas Major

and Iliacus group, Gluteus Medius and Minimus group, Tensor Fasciae Latae, Adductor muscle group and Gluteus

Maximus were strong (Grade 5). The Gracilis and Psoas Major were weak (Grade 4). The Sartorius was very weak

(Grade 3). Left Knee: The left Quadricep muscle group and Hamstring muscle group were strong (Grade 5). Right

Knee: The right Quadricep muscle group was strong (Grade 5). The Hamstring muscle group was weak (Grade 4).

Orthopedic Tests: Standing Tests: Trendelenburg's Test was positive bilaterally. Sitting Tests: Georges Testwas negative. The Maximum Cervical Compression Test was positive on the right side. The Shoulder








16/49





trigger points, and severe pain. The upper thoracic midline structures of the dorsum demonstrated articularfixations. The right upper thoracic group of the dorsum revealed malpositions, moderate muscle spasms, and active

trigger points. Palpation of the left mid thoracic group disclosed malpositions, moderate muscle spasms, activetrigger points, and severe pain. The mid thoracic midline structures demonstrated articular fixations, and severe




trigger points.

ASSESSMENT/TREATMENT:The following continues to be the modalities performed on Ms. Harper:

Today's Modalities & Procedures: These were the procedures that were performed and/or recommended today:cervical traction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the



recovery.


physiotherapy.



Cervical traction


Ice (cryo) therapy






segments.







FUTURE CARE PLAN:What follows continues to be the plan for Ms. Harper's future care:

Present Care Phase: Presently, Ms. Harper is in a relief phase of care.



17/49


times a week.

Goals of Treatment Plan: The preceding treatment plan has the goal of decreasing pain, decreasing swelling and

inflammation, decreasing spasms, increasing strength, stabilizing segments, correcting muscle imbalance andincreasing flexibility.


18/49


The patient named above came to our office on April 22, 2010 for treatment.


An assessment of Ms. Harper's current signs and symptoms was performed today. The patient's neck pain hasimproved a lot since her last visit with us. It was 4 on the 1 to 10 Pain Scale. It bothers her between 25% and 50%of the time she is awake. Her daily activities are currently somewhat affected by this symptom. She stated that her

frontal headache complaint was 4 today, on the 1 to 10 Pain Scale. It's experienced between 25% and 50% of the

time she is awake. The patient's daily activities are somewhat affected by this symptom. Ms. Harper's upper back

pain was 8 today, on the 1 to 10 scale. It bothers her between 51% and 75% of the time she is awake. Her daily

activities are presently seriously affected by this symptom.

OBJECTIVE EVALUATION:Cranial Nerve Exam: An examination of the Cranial Nerves found them all to be within normal limits. Sensory

Deficit Testing: There was no loss of sensibility, abnormal sensation, or pain noted in any of the upper or lower

dermatomes tested. Postural Evaluation: The patient's spine, extremities, gait, etc., were thoroughly inspected

visually revealing anomalies which included cervical muscle tension bilaterally, a high shoulder on the left, thoracic

muscle tension bilaterally, lumbar muscle tension bilaterally, a neck curvature to the left, cervical hypolordosis, athoracic curvature to the right and walking in a stiff/guarded manner.

Range of Motion Studies: In order to evaluate the patient's present condition with regard to spinal joint motion,





Extension: 0 degrees (norm = 0-59), with pain and spasm. Flexion: 35 degrees (norm = 50), with pain and spasm.

Left rotation: 30 degrees (norm = 30), with pain and spasm. Right rotation: 30 degrees (norm = 30), with pain andspasm.






3). Right Shoulder: The right Rhomboid muscle group, Latissimus Dorsi and Infraspinatus were strong (Grade 5).The Levator Scapulae, Serratus Anterior, Teres Minor, Deltoid (Posterior Division), Deltoid (Middle Division) and

Subscapularis were weak (Grade 4). The Supraspinatus, Pectoralis Major, Pectoralis Minor and Deltoid (AnteriorDivision) were very weak (Grade 3). Lower Extremities: Left Hip: The left Sartorius, Gluteus Medius and

Minimus group, Tensor Fasciae Latae, Adductor muscle group, Gracilis and Gluteus Maximus were strong (Grade














19/49





Palpation of the left upper thoracic group of the dorsum disclosed malpositions, moderate muscle spasms, activetrigger points, and severe pain. The upper thoracic midline structures of the dorsum demonstrated articular

fixations. The right upper thoracic group of the dorsum revealed malpositions, moderate muscle spasms, and activetrigger points. Palpation of the left mid thoracic group disclosed malpositions, moderate muscle spasms, active





trigger points.

ASSESSMENT/TREATMENT:Today's Modalities & Procedures: Following were the modalities used and/or recommended today: cervicaltraction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following the accident,



recovery.


physiotherapy.



Cervical traction


Ice (cryo) therapy






segments.







FUTURE CARE PLAN:Present Care Phase: Ms. Harper is presently in a relief phase of care.

Future Treatment Plan: Ms. Harper's future care plan includes home exercises, cryotherapy, long axis traction,



20/49

Goals of Treatment Plan: The goals intended to be achieved with the preceding treatment plan are decreasing

pain, decreasing swelling and inflammation, decreasing spasms, increasing strength, stabilizing segments, correcting



21/49

Re: Ms. Chelsea Harper - Visit Date: Monday, April 26, 2010

The patient named above came to our office on April 26, 2010 for treatment.


An assessment was performed on Ms. Harper to determine her current signs and symptoms. The patient's neck painwas 4 on the 1 to 10 Pain Scale. It bothers her between 25% and 50% of the time she is awake. Her daily activitiesare currently somewhat affected by this symptom. Ms. Harper's frontal headache complaint has improved

significantly. On the 1 to 10 scale today, this complaint was rated at 2. It's experienced less than 25% of the time

she is awake. This symptom is not presently affecting her daily activities. Her upper back pain was 8 today, on the

1 to 10 scale. It bothers her between 51% and 75% of the time she is awake. Presently, the patient's daily activities

are seriously being affected by this symptom.


Deficit Testing: All upper and lower dermatomes were found to be within normal limits, with no loss of sensibility,

abnormal sensation, or pain noted. Postural Evaluation: Ms. Harper's spine, gait, extremities, etc., were given a

thorough visual inspection revealing anomalies which included cervical muscle tension bilaterally, thoracic muscle

tension bilaterally, lumbar muscle tension bilaterally, cervical hypolordosis and walking in a stiff/guarded manner.

Range of Motion Studies: The patient's range of motion capacity was examined to evaluate her present condition

with regard to spinal joint motion: Cervical Spine: Flexion: 40 degrees (norm = 50), with pain and spasm.

Extension: 45 degrees (norm = 60), with pain and spasm. Left lateral flexion: 40 degrees (norm = 45), with pain and

spasm. Right lateral flexion: 40 degrees (norm = 45), with pain and spasm. Left rotation: 60 degrees (norm = 80),

with pain and spasm. Right rotation: 55 degrees (norm = 80), with pain and spasm. Thoracic Spine: Extension: 15

degrees (norm = 0-59), with pain and spasm. Flexion: 40 degrees (norm = 50), with pain and spasm. Left rotation:

30 degrees (norm = 30), with pain and spasm. Right rotation: 30 degrees (norm = 30), with pain and spasm.







The Levator Scapulae, Serratus Anterior, Teres Minor, Deltoid (Posterior Division), Deltoid (Middle Division) and


Minimus group, Tensor Fasciae Latae, Adductor muscle group, Gracilis and Gluteus Maximus were strong (Grade5). The Psoas Major and Iliacus group and Psoas Major were weak (Grade 4). Right Hip: The right Psoas Major






was negative. The Maximum Cervical Compression Test was positive on the right side. The ShoulderCompression Test was positive bilaterally. Supine Tests: Soto-Hall Test was positive, with the patients pain








22/49






trigger points, and severe pain. The mid thoracic midline structures demonstrated articular fixations, and severepain. The right mid thoracic group revealed malpositions, mild muscle spasms, and active trigger points. Palpation



trigger points.


cervical traction, cryotherapy and chiropractic adjustments. During the initial, intensive care period following theaccident, Ms. Harper was instructed to apply alternating hot and cold compresses to the injured area.


recovery.


physiotherapy.



Cervical traction


Ice (cryo) therapy



Therapeutic massage

Resistive exercisesThe above was for the purpose of decreasing pain, decreasing swelling and inflammation, decreasing spasms,


segments.





Prognosis: At this time, Ms. Harper's prognosis is good. Her case is somewhat complicated, but continuedimprovement is expected, despite permanent residuals being a possibility.

FUTURE CARE PLAN:The following plan remains virtually unchanged since Ms. Harper's last visit:Present Care Phase: As of today's visit, Ms. Harper is in a relief phase of care.




23/49

times a week.

Goals of Treatment Plan: The preceding treatment plan has the goal of decreasing pain, decreasing swelling and




24/49


On April 29, 2010, Ms. Harper came to our office for treatment.


An assessment of Ms. Harper's current signs and symptoms was performed today. Her neck pain has slightlyimproved since her last visit. It was 4 on the 1 to 10 Pain Scale. It affects her less than 25% of the time she isawake. Her daily activities are not presently being affected by this symptom. She stated that her frontal headache

complaint was 2 today, on the 1 to 10 Pain Scale. It's experienced less than 25% of the time she is awake. This

symptom is not presently affecting her daily activities. Her upper back pain is unchanged and is still at 8 on the Pain

Scale. It bothers her between 51% and 75% of the time she is awake. Presently, the patient's daily activities are

seriously being affected by this symptom.

OBJECTIVE EVALUATION:Cranial Nerve Exam: A Cranial Nerve examination found them all to be within normal limits. Sensory Deficit

Testing: All upper and lower dermatomes were found to be within normal limits, with no loss of sensibility,

abnormal sensation, or pain noted. Postural Evaluation: The patient's spine, extremities, gait, etc., were

thoroughly inspected visually revealing anomalies which included cervical muscle tension bilaterally, thoracic

muscle tension bilaterally, lumbar muscle tension bilaterally, cervical hypolordosis and walking in a stiff/guardedmanner.

Range of Motion Studies: In order to evaluate the patient's present condition with regard to spinal joint motion,





Extension: 15 degrees (norm = 0-59), with pain and spasm. Flexion: 40 degrees (norm = 50), with pain and spasm.

Left rotation: 30 degrees (norm = 30), with pain and spasm. Right rotation: 30 degrees (norm = 30), with pain andspasm.






3). Right Shoulder: The right Rhomboid muscle group, Latissimus Dorsi and Infraspinatus were strong (Grade 5).The Levator Scapulae, Serratus Anterior, Teres Minor, Deltoid (Posterior Division), Deltoid (Middle Division) and


Minimus group, Tensor Fasciae Latae, Adductor muscle group, Gracilis and Gluteus Maximus were strong (Grade














25/49





Palpation of the left upper thoracic group of the dorsum disclosed malpositions, moderate muscle spasms, activetrigger points, and severe pain. The upper thoracic midline structures of the dorsum demonstrated articular






trigger points.

ASSESSMENT/TREATMENT:The following modalities performed remain virtually unchanged since Ms. Harper's last visit:Today's Modalities & Procedures: Today's procedures and/or recommendations included: cervical traction,

cryotherapy and chiropractic adjustments. During the initial, intensive care period following the accident, Ms.Harper was instructed to apply alternating hot and cold compresses to the injured area.


recovery.


physiotherapy.



Cervical traction


Ice (cryo) therapy



Resistive exercises



segments.







FUTURE CARE PLAN:The following continues to be the plan for Ms. Harper's future treatment:Present Care Phase: As of today's visit, Ms. Harper is in a relief phase of care.


26/49



times a week.

Goals of Treatment Plan: The goals intended to be achieved with the preceding treatment plan are decreasingpain, decreasing swelling and inflammation, decreasing spasms, increasing strength, stabilizing segments, correcting



27/49

Re: Ms. Chelsea Harper - Visit Date: Tuesday, May 4, 2010

Ms. Harper presented herself at our office on May 4, 2010 for treatment.


Ms. Harper's current signs and symptoms were assessed today. The patient's neck pain was 4 on the 1 to 10 PainScale. It affects her less than 25% of the time she is awake. Her daily activities are not presently being affected bythis symptom. She stated that her frontal headache complaint was 2 today, on the 1 to 10 Pain Scale. It's

experienced less than 25% of the time she is awake. This symptom is not presently affecting her daily activities.

Her upper back pain has seen some slight improvement. On the 1 to 10 scale, it was 6. It bothers her between 51%

and 75% of the time she is awake. Presently, the patient's daily activities are seriously being affected by this

symptom.


Deficit Testing: All upper and lower dermatomes were found to be within normal limits, with no loss of sensibility,

abnormal sensation, or pain noted. Postural Evaluation: Ms. Harper's spine, gait, extremities, etc., were given a

thorough visual inspection revealing anomalies which included cervical muscle tension bilaterally, thoracic muscle

tension bilaterally, lumbar muscle tension bilaterally, cervical hypolordosis and walking in a stiff/guarded manner.

Range of Motion Studies: The following is an evaluation of the patient's present condition with regard to spinal

joint motion. Cervical Spine: Flexion: 40 degrees (norm = 50), with pain and spasm. Extension: 45 degrees (norm

= 60), with pain and spasm. Left lateral flexion: 40 degrees (norm = 45), with pain and spasm. Right lateral flexion:

40 degrees (norm = 45), with pain and spasm. Left rotation: 60 degrees (norm = 80), with pain and spasm. Right

rotation: 55 degrees (norm = 80), with pain and spasm. Thoracic Spine: Extension: 15 degrees (norm = 0-59), with

pain and spasm. Flexion: 40 degrees (norm = 50), with pain and spasm. Left rotation: 30 degrees (norm = 30), with

pain and spasm. Right rotation: 30 degrees (norm = 30), with pain and spasm.







The Levator Scapulae, Serratus Anterior, Teres Minor, Deltoid (Posterior Division), Deltoid (Middle Division) and


Minimus group, Tensor Fasciae Latae, Adductor muscle group, Gracilis and Gluteus Maximus were strong (Grade5). The Psoas Major and Iliacus group and Psoas Major were weak (Grade 4). Right Hip: The right Psoas Major






was negative. The Maximum Cervical Compression Test was positive on the right side. The ShoulderCompression Test was positive bilaterally. Supine Tests: Soto-Hall Test was positive, with the patients pain








28/49






trigger points, and severe pain. The mid thoracic midline structures demonstrated articular fixations, and severepain. The right mid thoracic group revealed malpositions, mild muscle spasms, and active trigger points. Palpation

harper chelsea

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