CHIROPRACTIC
TREATMENT PLAN
BY: Darah DeKam
INITIAL REPORT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET:3/7/2021
1. Incident of Injury: The patient states that he was struck from the side in a recent car accident.
Neck received a lot of damage along with bruises on shoulder and ribs.
2. Patient's Complaints: The patient presented himself to this clinic on 3/8/2020 exhibiting the
following complaints and symptoms:
Neck pain
Back pain
Ribs on right side are bruised
Right shoulder bruised
3. Objective Findings
A thorough chiropractic exam was given on 3/8/2020.
Vital statistics are: Height 6,1” Weight 197 lbs., BP 125/78, Pulse 74 BPM.
Visual inspection demonstrated a patient moderately guarded in certain movements of the neck, and
at the upper torso, and at the waist.
Palpatory inspection revealed muscle spasms present at the neck regions.
Tenderness was displayed at those same regions with static palpation.
Loss of coupled motion was noted in the upper cervical spine.
Reductions in range of motion (ROM) was noted as listed below:
CERVICAL RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
30/50 25/60 28/45 27/45 75/80 75/80
Norm- 55-60° Norm- 55-60° Norm- 35-45° Norm- 35-45° Norm- 75-85° Norm- 75-85°
THORACOLUMBULAR RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
20/45 15/45 10/40 10/40 30/35 30/35
Norm- 25-45° Norm- 25-45° Norm- 20-40° Norm- 20-40° Norm- 30-35° Norm- 30-35°
Muscle testing revealed +4 weakness of neck flexors, extensors, and the bilateral neck flexors.
Reflex testing was within normal limits at the bilateral biceps, triceps, brachioradialis muscles, at the
patella, at the Achilles tendon.
X-Rays were deemed necessary to determine the presence of ligamentous stability, occult injury, and
for biomechanical analysis.
4. X-ray Findings: SEE ATTACHED REPORT.
5. Diagnosis: SEE ATTACHED REPORT.
6. Disability Data/Restrictions: The patient has been advised about the avoidance of re-injury
through restrictions on heavy or prolonged lifting or maintaining of rotational or overly flexed or
extended positions.
7. Care Plan: In order to promote healing and to relieve the patient's pain, I recommend the
following therapies and procedures:
SEE ATTACHED REPORT.
Interferential therapy to reduce muscle spasm, pain, and to tonify weakened muscles in the neck
regions.
A prescription may be made for a managed care. The patient will be advised on proper exercises and
stretches to support the care at home, and will be encouraged to move into an active role early, so
that he will continue to stretch the healing tissues during and after the office rehab program ends.
8. Examination Forms Attached? [ ] YES [X] NO
9. Additional Evaluations Attached? [ ] YES [X] NO
10. Accident Report Attached? [ ] YES [X] NO
_____________________________________________ ____________________
Signature Date
CARE PLAN AND DIAGNOSIS:
ACUTE EXTERNAL TRAUMA WITH SOFT TISSUE TRAUMA- MODERATE/SEVERE
DIAGNOSIS:
-Whiplash
-Herniated Disc
-Shoulder Pain
-Bruised Ribs
Herniated Disc occurs when the soft center of a spinal disc pushes through a crack in the tougher exterior
casing.
Whiplash occurs following damage to the neck, usually because of sudden extension and flexion.
Being struck by a moving object can jam joints, producing contusions in the surrounding soft tissues.
Rapid return to light and modified activities for best results.
APPROPRIATE CARE: Chiropractic adjusting, interferential therapy, rehabilitative exercise and
home cryotherapy (ice).
EXPECTED FREQUENCY AND DURATION OF CARE: Based upon degree of trauma, 3-5
sessions per week initially, decreasing in frequency afterwards. Long term follow-up is essential as many
symptoms may not begin until 6-8 weeks post trauma. Follow-up should be expected FOR 3-5 months but
may be longer if treatment is delayed. Modified work restrictions likely for 2-4 weeks. TOTAL: 18-24
SESSIONS OVER 3-5 MONTHS.
WEEK CARE PROGRESS M T W T F S
1-2 Initial Report 30% pain reduction
Pain control (Ice) 30% increase in ROM X X X
Interferential therapy
Gentle adjusting 3-5 /week
Home Exercise
3-6 Same as above 30-50% pain reduction X X
Progress Report (Week 3 & 6) 30-50% imp. ROM
2-3 /week
7-12 More aggressive adjusting 50-75% pain relief X
Home exercise
Interferential therapy 1-2 /week
Progress Report (Week 9 & 12)
13+ Interferential therapy Gradual improvement
Aggressive active exercise Discharge
Progress Report (Week 15) Residual treatment possible
2-3 /month
REDUCE THESE FACTORS: Activities of daily living or stresses are likely to cause a flare up
requiring additional sessions. The likelihood of is less if you follow home instructions.
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Is still in a lot of pain from incident. Has been icing and taking pain medication to help
with it. Neck is still very sore and hard to move. Bruises on ribs have become a deep purple
color, but the pain has lessened. Has taken time off work. Shoulder pain seems to be from
bruising.
NOTES:
I did gentle adjustments on patient today. Feeling around the neck showed me that he was
still in a lot of pain and discs were out severely. Made him do light band exercises and other neck
stretching to help with recovery. Also had him do interferential therapy.
SIGNATURE DATE: 3/10/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Still in a lot of pain from incident. Is taking pain medication and is icing to help manage
it. Tried to lift something yesterday and it made his neck and shoulder feel worse. Has a 3 week
leave from work before he goes back for a limited number of hours per day.
NOTES:
I did gentle adjusting on neck for herniated disc and on the back to keep everything
aligned. Very tender on the neck but it seemed to move better today. Made him do the same light
exercises rom before and did interferential therapy today as well.
SIGNATURE DATE: 3/13/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Pain in neck and upper back. Thinks he slept wrong causing his upper back to feel out of
place. Has been taking pain medication and icing to relieve it. Bruises on ribs and shoulder are
almost gone. Still is not at work.
NOTES:
Neck was a little bit harder to adjust today because of the sleeping injury to the upper
back. Wanted to add in a few more exercises, but do not think he is ready to move on quite yet.
Did Interferential therapy on neck and upper back.
SIGNATURE DATE: 3/15/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck has started to feel a little bit better and is still taking the same dosage of pain
medication. Bruises on ribs are completely gone. Returns to work in 2 weeks for half time.
NOTES:
Still only able to do light adjustments on neck. Is moving well and responding to
therapies. Added in a few more exercises to do at home and did interferential therapy on patient
neck.
SIGNATURE DATE: 3/17/2
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck is feeling stiff. Forgot to do exercises yesterday because of son’s basketball game.
Did remember to ice though. Shoulder bruises are almost gone.
NOTES:
Adjusting was a bit harder today. Definitely could tell he forgot to do home exercises.
Did therapy exercises and interferential therapy on the neck muscles.
SIGNATURE DATE: 3/20/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck and upper back are still sore and stiff. Remembered to do exercises and iced neck.
Returns to work next week for a limited number of hours.
NOTES:
Did regular gentle adjustments on neck and back regions. Everything moved well today
and I am thinking about adding new exercises after the three week progress report. Did exercises
and interferential therapy.
SIGNATURE DATE: 3/23/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
A lot of pain in the neck today. Forgot to take pain medication prior to the appointment.
Asked if returning to work would be possible next week.
NOTES:
Had to be very gentle with adjusting today. Could only do some of the adjustments on the
neck because of the pain. Did interferential therapy and iced neck. Did not make him do
exercises because of the pain.
SIGNATURE DATE: 3/26/21
PROGRESS REPORT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
1. Incident of Injury: SEE INITIAL REPORT
2. A) Initial Patient Complaints: SEE INITIAL REPORT
B) Present Patient Complaints: Constant, dull pain, which increased with certain movements
of the neck and upper torso. The patient said that it was difficult to find positions to reduce
symptoms. Pain was relieved with the use of pain relievers and ice and has remained the same since
onset.
3. A) Initial Objective Findings: SEE INITIAL REPORT
B) Present Objective Findings:
A thorough chiropractic re-exam was given on 3/29/21.
Visual inspection demonstrated the patient is moderately guarded in certain movements at the neck
and upper torso.
Palpatory inspection revealed muscle spasm present at the neck regions.
Tenderness was displayed at those same regions with static palpation.
Loss of coupled motion was noted in the upper cervical spine.
Reductions in range of motion (ROM) was noted as listed below:
CERVICAL RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
33/60 30/60 29/45 29/45 74/80 75/80
Norm- 55-60° Norm- 55-60° Norm- 35-45° Norm- 35-45° Norm- 75-85° Norm- 75-85°
THORACOLUMBULAR RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
17/45 18/45 12/40 13/40 31/35 31/35
Norm- 25-45° Norm- 25-45° Norm- 20-40° Norm- 20-40° Norm- 30-35° Norm- 30-35°
Upper score is present evaluation and lower score is normal values.
Muscle testing revealed +4 weakness of neck flexors, extensors, and the bilateral neck flexors.
4. X-ray Findings: SEE INITIAL REPORT
5. Diagnosis: SEE INITIAL REPORT
6. Disability Data/Restrictions: The patient has been advised about the avoidance of re-injury
through restrictions on heavy or prolonged lifting or maintaining of rotational or overly flexed or
extended positions.
7. Care Recommendations: In order to promote healing and to relieve the patient's pain, I
recommend the following therapies and procedures:
Chiropractic adjustments/manipulation of the cervical, thoracic, and lumbar regions for 2-3X per
week for 3 weeks, followed by a re-evaluation every 3 weeks.
Interferential therapy to reduce muscle spasm, pain and to tonify weakened muscles in the neck
region.
A prescription was made for managed care. The patient will be advised on proper exercises and
stretches to support the care at home, and will be encouraged to move into an active role early, so
that he will continue to stretch the healing tissues during and after the office rehab program ends.
__________________________ _______________
Signature Date
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Has been doing the new exercises I gave to him at three-week check in. Neck and back
are feeling better. Pain medication has been restricted to a lower dosage. Returned to work for
four hours a day.
NOTES:
Gave him new exercises to do at home at last appointment. Adjusting went smoothly and
did not seem to cause him any pain. Did interferential therapy on his neck muscles and did new
exercises.
SIGNATURE DATE: 4/2/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck is sore from new exercises, but a good sore. Is starting to feel like it is getting better
and healing. Work is sometimes difficult but ices whenever he starts to feel the pain setting in.
NOTES:
I am still doing gentle adjustments to make sure to not introduce him to too much at a
time. The adjustments are moving well. Did exercises and interferential therapy.
SIGNATURE DATE: 4/6/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Work is taking a toll on his neck. Doesn’t know if he should take a week off to let it heal
some more or not. Has been icing more frequently.
NOTES:
Neck was a bit sorer today when adjusting, but I think it is still healing nicely. Told
patient he does not need to take time off work and should push through this next week. I think it
will help him get over the hump. Did interferential therapy and exercises.
SIGNATURE DATE: 4/9/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Went to work like I told him on Monday. Made sure to ice it well the night before and
after. Neck is holding up well pain-wise so far. Exercises are helping his flexibility.
NOTES:
Adjusting was painless today. A few ribs were out of place but that’s an easy fix. Gave
him the choice of doing interferential therapy today. Did neck exercises.
SIGNATURE DATE: 4/13/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck is feeling good despite a long week of work. Felt sore from me putting his ribs
backs in place. Has been doing exercises.
NOTES:
Easy adjustments today. Last appointment before 6-week check in. He should be at
almost 50% less pain by then. Did interferential therapy and exercises.
SIGNATURE DATE: 4/16/21
PROGRESS REPORT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
1. Incident of Injury: SEE INITIAL REPORT
2. A) Initial Patient Complaints: SEE INITIAL REPORT
B) Present Patient Complaints: Occasional, dull pain, which increased with certain movements
of the neck and upper torso. The patient said that it was difficult to find positions to reduce
symptoms. Pain was relieved with the use of pain relievers and ice and has gotten slightly better
since onset.
3. A) Initial Objective Findings: SEE INITIAL REPORT
B) Present Objective Findings:
A thorough chiropractic re-exam was given on 4/19/21.
Visual inspection demonstrated the patient is moderately guarded in certain movements at the neck
and upper torso.
Palpatory inspection revealed muscle spasm present at the neck regions.
Tenderness was displayed at those same regions with static palpation.
Loss of coupled motion was noted in the upper cervical spine.
Reductions in range of motion (ROM) was noted as listed below:
CERVICAL RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
36/60 36/60 30/45 29/45 75/80 75/80
Norm- 55-60° Norm- 55-60° Norm- 35-45° Norm- 35-45° Norm- 75-85° Norm- 75-85°
THORACOLUMBULAR RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
19/45 19/45 14/40 13/40 31/35 31/35
Norm- 25-45° Norm- 25-45° Norm- 20-40° Norm- 20-40° Norm- 30-35° Norm- 30-35°
Upper score is present evaluation and lower score is normal values.
Muscle testing revealed +4 weakness of neck flexors, extensors, and the bilateral neck flexors.
4. X-ray Findings: SEE INITIAL REPORT
5. Diagnosis: SEE INITIAL REPORT
6. Disability Data/Restrictions: The patient has been advised about the avoidance of re-injury
through restrictions on heavy or prolonged lifting or maintaining of rotational or overly flexed or
extended positions.
7. Care Recommendations: In order to promote healing and to relieve the patient's pain, I
recommend the following therapies and procedures:
Chiropractic adjustments/manipulation of the cervical, thoracic, and lumbar regions for 1-2X per
week for 4 weeks, followed by a re-evaluation every 3 weeks.
High Volt DC current therapy to reduce edema, muscle spasm and pain in the cervical region.
A prescription will be continued for managed care. The patient will be advised on proper exercises
and stretches to support the care at home, so that he will continue to stretch the healing tissues during
and after the office rehab program ends.
_____________________________________ _______________
Signature Date
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck still has occasional pain. Is going to increase his hours at work next week. Back and
knees are a bit sore from lifting things at home.
NOTES:
Did adjustments on his neck and back. Everything is moving as it should. Gave him the
option of doing interferential therapy or not on both neck and back. Also did exercises.
SIGNATURE DATE: 4/22/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Hours were increased at work this week. Is back to full-time. Everything else feels pretty
good for the most part. Is still taking pain meds, but they are a lower dosage.
NOTES:
Started doing more aggressive adjusting on him today. Everything has been healing well,
but I have been doing more gentle adjustments. Did interferential therapy and exercises.
SIGNATURE DATE: 4/27/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Was sore from my more aggressive adjustments. Neck still hurts in certain angles. Has
been icing and doing exercises.
NOTES:
Did more aggressive adjustments again today. If he is getting extremely sore, I will
reduce back to more gentle. Did interferential therapy and exercises.
SIGNATURE DATE: 4/30/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Is happy to be in today. Has been a few days since last adjustment and thinks a rib is out
of place. Has been doing full-time at job still and thinks he is feeling almost 75% back to normal.
NOTES:
Put his rib back in place and did aggressive adjusting on neck. Will most likely reduce
number of visits at 9-week check-up. Did interferential therapy and exercises.
SIGNATURE DATE: 5/5/21
PROGRESS REPORT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
1. Incident of Injury: SEE INITIAL REPORT
2. A) Initial Patient Complaints: SEE INITIAL REPORT
B) Present Patient Complaints: Occasional, dull pain, which increased with certain movements
of the neck and upper torso. The patient said that it was sometimes hard to find positions to reduce
symptoms. Pain was relieved with the use of pain relievers and ice and has gotten better since onset.
3. A) Initial Objective Findings: SEE INITIAL REPORT
B) Present Objective Findings:
A thorough chiropractic re-exam was given on 5/10/21.
Visual inspection demonstrated the patient is somewhat guarded in certain movements at the neck
and upper torso.
Palpatory inspection revealed muscle spasm present at the neck regions.
No tenderness with static palpation.
Loss of coupled motion was noted in the upper cervical spine.
Reductions in range of motion (ROM) was noted as listed below:
CERVICAL RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
43/60 44/60 31/45 30/45 75/80 76/80
Norm- 55-60° Norm- 55-60° Norm- 35-45° Norm- 35-45° Norm- 75-85° Norm- 75-85°
THORACOLUMBULAR RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
21/45 20/45 16/40 14/40 33/35 31/35
Norm- 25-45° Norm- 25-45° Norm- 20-40° Norm- 20-40° Norm- 30-35° Norm- 30-35°
Upper score is present evaluation and lower score is normal values.
Muscle testing revealed +3 weakness of neck flexors, extensors, and the bilateral neck flexors.
4. X-ray Findings: SEE INITIAL REPORT
5. Diagnosis: SEE INITIAL REPORT
6. Disability Data/Restrictions: The patient has been advised about the avoidance of re-injury
through restrictions on heavy or prolonged lifting or maintaining of rotational or overly flexed or
extended positions.
7. Care Recommendations: In order to promote healing and to relieve the patient's pain, I
recommend the following therapies and procedures:
Chiropractic adjustments/manipulation, of the cervical, thoracic, and lumbar regions for 1-2X per
week for 3 weeks, followed by a re-evaluation every 3 weeks.
Interferential therapy to reduce muscle spasm, pain and to tonify weakened muscles in the neck
region.
A prescription will be continued for managed care. The patient will be advised on proper exercises
and stretches to support the care at home, so that he will continue to stretch the healing tissues during
and after the office rehab program ends.
_____________________________________ _______________
Signature Date
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck is feeling good for most of the days. Took his last pain medicine dosage today. Has
reduced to icing every other day.
NOTES:
Did adjustments and gave him the option of doing interferential therapy and exercises
here or going home and doing exercises there.
SIGNATURE DATE: 5/13/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck feels good. Hasn’t really been hurting him at work. Forgot to do exercises one day
last week, but it didn’t really seem to affect him.
NOTES:
He has gotten used to the more aggressive adjusting and it seems his neck and back are
accustomed to it. Told him he did not need to do interferential therapy anymore if he did not
want to. Did exercises.
SIGNATURE DATE: 5/21/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Feels like his neck is back up to 90%. Has stopped icing unless pain starts up. Work is
still going well.
NOTES:
Adjusting went smoothly and it seems like everything is about lined up. Last visit before
the 12-week check-in. Will probably only need to see him a couple more times.
SIGNATURE DATE: 5/25/21
PROGRESS REPORT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
1. Incident of Injury: SEE INITIAL REPORT
2. A) Initial Patient Complaints: SEE INITIAL REPORT
B) Present Patient Complaints: Dull pain, which only happened with certain movements of the
neck and upper torso. The pain was relieved with the use of ice and has gotten better since onset.
3. A) Initial Objective Findings: SEE INITIAL REPORT
B) Present Objective Findings:
A thorough chiropractic re-exam was given on 5/31/21.
Visual inspection demonstrated the patient is somewhat guarded in certain movements at the neck
and upper torso.
Palpatory inspection revealed no muscle spasms present.
No tenderness with static palpation.
Loss of coupled motion was noted in the upper cervical spine.
Reductions in range of motion (ROM) was noted as listed below:
CERVICAL RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
50/60 49/60 32/45 33/45 75/80 76/80
Norm- 55-60° Norm- 55-60° Norm- 35-45° Norm- 35-45° Norm- 75-85° Norm- 75-85°
THORACOLUMBULAR RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
23/45 22/45 18/40 17/40 33/35 31/35
Norm- 25-45° Norm- 25-45° Norm- 20-40° Norm- 20-40° Norm- 30-35° Norm- 30-35°
Upper score is present evaluation and lower score is normal values.
Muscle testing revealed +2 weakness of neck flexors, extensors, and the bilateral neck flexors.
4. X-ray Findings: SEE INITIAL REPORT
5. Diagnosis: SEE INITIAL REPORT
6. Disability Data/Restrictions: The patient has been advised about the avoidance of re-injury
through restrictions on heavy or prolonged lifting or maintaining of rotational or overly flexed or
extended positions.
7. Care Recommendations: In order to promote healing and to relieve the patient's pain, I
recommend the following therapies and procedures:
Chiropractic adjustments of the cervical, thoracic, and lumbar regions for 2-3X per month for 3
weeks, followed by a re-evaluation every 3 weeks.
Interferential therapy to reduce muscle spasm, pain and to tonify weakened muscles in the neck
region.
A prescription will be continued for managed care. The patient will be advised on proper exercises
and stretches to support the care at home, so that he will continue to stretch the healing tissues during
and after the office rehab program ends.
_____________________________________ _______________
Signature Date
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck feels great and almost never has pain anymore. Hasn’t had to ice in over a few
days.
NOTES:
Neck adjusts well and it is almost at 100%. Told him he did not have to do exercises
unless it started acting up more.
SIGNATURE DATE: 6/9/21
REGULAR VISIT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
PATIENT COMPLAINTS:
Neck hasn’t had any issues in weeks. Full-time work schedule is going well and isn’t
affecting it.
NOTES:
Everything looks good and aligned. I expect to discharge him at the next progress check-
in. No pain with any angle of neck or adjustment.
SIGNATURE DATE: 6/16/21
PROGRESS REPORT:
PATIENT: Jim Smith
EMPLOYER: DeKam Chiropractic
DATE OF INJURY/ONSET: 3/7/2020
1. Incident of Injury: SEE INITIAL REPORT
2. A) Initial Patient Complaints: SEE INITIAL REPORT
B) Present Patient Complaints: No pain. The patient said that any pain was relieved with the
use of ice and is better since onset.
3. A) Initial Objective Findings: SEE INITIAL REPORT
B) Present Objective Findings:
A thorough chiropractic re-exam was given on 6/21/21.
Visual inspection demonstrated the patient is not guarded in certain movements at the neck and upper
torso.
Palpatory inspection revealed no muscle spasms present.
No tenderness with static palpation.
Loss of coupled motion was not noted.
Reductions in range of motion (ROM) was noted as listed below:
CERVICAL RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
55/60 57/60 37/45 38/45 75/80 76/80
Norm- 55-60° Norm- 55-60° Norm- 35-45° Norm- 35-45° Norm- 75-85° Norm- 75-85°
THORACOLUMBULAR RANGE OF MOTION
FLEXION EXTENSION L. LATERAL R. LATERAL LEFT RIGHT
FLEXION FLEXION ROTATION ROTATION
27/45 26/45 23/40 24/40 33/35 31/35
Norm- 25-45° Norm- 25-45° Norm- 20-40° Norm- 20-40° Norm- 30-35° Norm- 30-35°
Upper score is present evaluation and lower score is normal values.
Muscle testing revealed no weakness of neck flexors, extensors, and the bilateral lateral neck flexors.
4. X-ray Findings: SEE INITIAL REPORT
5. Diagnosis: SEE INITIAL REPORT
6. Disability Data/Restrictions: The patient has been advised about the avoidance of re-injury
through restrictions on heavy or prolonged lifting or maintaining of rotational or overly flexed or
extended positions.
7. Care Recommendations: Patient has completed rehab program and does not need to come back
for Chiropractic adjustments pertaining to this injury.
The patient will be advised on proper exercises and stretches to support the care at home, so that he
will continue to stretch the healing tissues after the office rehab program ends.
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Signature Date
