Chart Notes - Vortala- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateralmuscle group of the mid thoracic, muscle group of the lower thoracic,

Patient: Main, Brittany Ins Co Pol # Insured

12/19/1985DOB:

Date 01/21/2016Provider Dr. Jacob Young

Chart NotesBrittany Main

401 S. Gilbert St.Iowa City, IA 52240Phone: (319) 337-6000Fax:

Black & Gold Chiropractic & Wellness

Subjective: Daily Encounter: treatment for acute/active care on visit #1- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral dull, sharp, aching, shooting and tightness/stiffness discomfort.- Subjective/Patient Assessment: Brittany stated this complaint has not changed since the last visit. Shereports her ability to participate with employment has not changed with this complaint while bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, reaching overhead, rising out of chair or bed, sitting, standing, staying asleep and walking. 9/10 reported using the Visual Analog Scale. Brittany indicated that the discomfort occurs approximately 80% of the time.Brittany was lifting "40lb boxes" at work on 1/18/2016. Felt tightness in the back while performing work duties and then woke up the following day with intense pain in the lower back. Brittany stated that upon standing "she about passed out" and couldn't move. She reports that it hurts to sit currently and it took her an estimated 15-20 minutes just to get dressed today. Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T6, T10, L1, L2, L3 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short right leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.

Assessment: ASSESSMENT:Brittany is of good health and is expected to make good progress and recovery with few residuals. She has overweight and no noted contraindications to chiropractic care. Based on her history and examination, it is reasonable to believe that her recovery may take about the same length of time as an average patient with an uncomplicated case. DIAGNOSIS:Upon consideration of the information available I have diagnosed Brittany Main with: (S33.5XXA) Sprain of lumbar ligts, initial, (S39.012A) Strain of lower back, (M62.830) Muscle spasm of back, (M54.5) Low back pain, (M99.03) Seg and somatic dysf of lumbar reg, (M99.04) Seg and somatic dysf of sacral reg, (M99.05) Seg and somatic dysf of pelvic reg, (S29.012A) Strain of back wall of thorax, (M54.6) Pain in thoracic spine, (M99.02) Seg and somatic dysf of thoracic reg

Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours

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Date 01/21/2016Provider Dr. Jacob Young *** continued from previous page ***

- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3, T6, T10, L1, L2, L3 and right pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 5:22. Completed at 5:30.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:30. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps



12/19/1985DOB:


Diagnosis S33.5XXA: Sprain of lumbar ligts, initialS39.012A: Strain of lower backM62.830: Muscle spasm of backM54.5: Low back painM99.03: Seg and somatic dysf of lumbar regM99.04: Seg and somatic dysf of sacral regM99.05: Seg and somatic dysf of pelvic regS29.012A: Strain of back wall of thoraxM54.6: Pain in thoracic spineM99.02: Seg and somatic dysf of thoracic reg

03/07/2016 03:02 PMProvider Signature X

with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 5:45.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









12/19/1985DOB:


Subjective: Daily Encounter: treatment for acute/active care on visit #2- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral dull, sharp, aching, shooting and tightness/stiffness discomfort.- Subjective/Patient Assessment: Brittany stated this complaint has improved since the last visit. She reportsher ability to participate with employment has improved with this complaint while bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, reaching overhead, rising out of chair or bed, sitting, standing, staying asleep and walking. 7/10 reported using the Visual Analog Scale. Brittany indicated that the discomfort occurs approximately 80% of the time.Brittany reported minor improvement over the weekend following the first adjustment. Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T6, T10, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short right leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.

Assessment: ASSESSMENT:Brittany is of good health and is expected to make good progress and recovery with few residuals. She has overweight and no noted contraindications to chiropractic care. Based on her history and examination, it is reasonable to believe that her recovery may take about the same length of time as an average patient with an uncomplicated case. DIAGNOSIS:Upon consideration of the information available I have diagnosed Brittany Main with: (S33.5XXA) Sprain of lumbar ligts, initial, (S39.012A) Strain of lower back, (M62.830) Muscle spasm of back, (M54.5) Low back pain, (M99.03) Seg and somatic dysf of lumbar reg, (M99.04) Seg and somatic dysf of sacral reg, (M99.05) Seg and somatic dysf of pelvic reg, (S29.012A) Strain of back wall of thorax, (M54.6) Pain in thoracic spine, (M99.02) Seg and somatic dysf of thoracic regDaily Assessment: showing improvement and meeting expectations as indicated in today's subjective.- Current Status: Improving because she is reporting less discomfort and is showing improved function.

Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following:






12/19/1985DOB:


bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3, T6, T10, L2, L4 and right pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 5:04. Completed at 5:12.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:12. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer:



12/19/1985DOB:




lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 5:27.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









12/19/1985DOB:


Subjective: Daily Encounter: treatment for acute/active care on visit #3- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral dull, sharp, aching, shooting and tightness/stiffness discomfort.- Subjective/Patient Assessment: Brittany stated this complaint has improved since the last visit. She reportsher ability to participate with employment has improved with this complaint while bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, reaching overhead, rising out of chair or bed, sitting, standing, staying asleep and walking. 6/10 reported using the Visual Analog Scale. Brittany indicated that the discomfort occurs approximately 60% of the time.

Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T4, T7, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short right leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.








12/19/1985DOB:


bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T4, T7, L2, L4 and right pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 10:44. Completed at 10:52.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 10:52. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer:



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Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T4, T7, T9, L2, L3 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short right leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.








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Brittany is leaving today for a previously scheduled vacation and will be continuing care upon return. Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T7, L1, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short right leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.


Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours






12/19/1985DOB:


- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3, T7, L1, L4 and right pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 11:41. Completed at 11:49.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 11:49. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps



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with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 12:04.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









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Brittany reports with slight increase in pain today following her trip. She also has been transferred for work and is having a difficult time getting here now. We will try to continue our current plan but she thinks it will be difficult with work. Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T7, T10, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short right leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.


Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued






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today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3, T7, T10, L2, L4 and right pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 11:02. Completed at 11:10.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 11:10. Therapeutic wobble chair: 25 reps each of



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side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 11:25.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









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Subjective: Daily Encounter: treatment for acute/active care on visit #9- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral dull, sharp, aching, shooting and tightness/stiffness discomfort.- Subjective/Patient Assessment: Brittany stated this complaint has stayed the same since the last visit. Shereports her ability to participate with employment has stayed the same with this complaint while bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, reaching overhead, rising out of chair or bed, sitting, standing, staying asleep and walking. 6/10 reported using the Visual Analog Scale. Brittany indicated that the discomfort occurs approximately 40% of the time.

Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T5, T9, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.


Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac






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and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T5, T9, L2, L4 and left pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 5:35. Completed at 5:43.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:43. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3



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03/10/2016 11:52 AMProvider Signature X

minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 5:58.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









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Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T2, T7, T11, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.








12/19/1985DOB:


and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T2, T7, T11, L4 and left pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 11:18. Completed at 11:26.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 11:26. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3



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12/19/1985DOB:



Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T4, T9, T11, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.








12/19/1985DOB:


and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T4, T9, T11, L4 and left pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 5:18. Completed at 5:26.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:26. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3



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12/19/1985DOB:



Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T4, T8, T11, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as severely reduced with pain noted.








12/19/1985DOB:


and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T4, T8, T11, L2, L4 and left pelvis spinal level(s). ------- Traction: Y-Axis mechanical traction applied to thoraco-lumbar, upper lumbar, lower lumbar and lumbo-sacral for 8 minutes. Exercise began at 10:25. Completed at 10:33.- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 10:33. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3



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12/19/1985DOB:


Subjective: Daily Encounter: treatment for acute/active care on visit #13- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral dull, sharp, aching, shooting and tightness/stiffness discomfort.- Subjective/Patient Assessment: Brittany stated this complaint has stayed the same since the last visit. Shereports her ability to participate with employment has stayed the same with this complaint while bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, reaching overhead, rising out of chair or bed, sitting, standing, staying asleep and walking. 3/10 reported using the Visual Analog Scale. Brittany indicated that the discomfort occurs approximately 40% of the time.Systems Review: (since most recent evaluation) - Musculoskeletal: Other than presenting musculoskeletal complaints (see examination) patient reports no additional musculoskeletal complaints. - Neurological: Other than presenting complaints (see examination) patient reports no additional neurological complaints and denies: temporary loss of smell, vision or hearing. - Head & ENT: Reports no update or change - Cardiovascular: Reports no update or change. - Respiratory: Reports no update or change. - Gastrointestinal: Reports no update or change. - Genitourinary: Reports no update or change. - Endocrine: Reports no update or change. - Derma./Hema: Reports no update or change. Past, Family and Social History: (since initial evaluation) - Past Health History: - Surgery: no new surgeries reported - Medications: no new or deleted medications - Illnesses: no change in family health history - Accidents: no new trauma reported since initial intake - Family and Social History: - Family History: no change in family health history - Work Habits: no change in work habits since condition began - Social Habits: no change in social habits - Exercise Habits: no changes in exercise habits - Diet and Nutrition: no changes in diet or nutrition

Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T7, T11, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral.






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- ROM Concern(s): entire lumbar spine and thoracic extension was recorded as mildly reduced with pain noted.Constitutional - Vital Signs: Pulse: 77 bpm.Constitutional - Vital Signs: BP: 118/84 mm/Hg, right armConstitutional - Vital Signs: Respiration: 14 breaths per minute, and regular. Neuro-Mental Status: evaluations performed and the patient was observed to be alert and oriented X 3 (person place time) and cooperative .Neuro-Deep Tendon Reflexes (normal 2+):- Patellar Left 2+, Right 2+,- Achilles Left 2+, Right 2+,Neuro-Lower extremity resistive isometric motor testing (normal 5/5):- Iliopsoas: Left: 5 / 5 Right: 5 / 5- Quadriceps: Left: 5 / 5 Right: 5 / 5- Anterior Tibialis: Left: 5 / 5 Right: 5 / 5- Hallucis Longus: Left: 5 / 5 Right: 5 / 5- Ext Digitorum Longus & Brevis: Left: 5 / 5 Right: 5 / 5- Gluteus Medius: Left: 5 / 5 Right: 5 / 5Ortho-Valsalva's Maneuver performed. Patient indicated no pain.Ortho-Slump's test performed bilaterally. Patient indicated mild on the bilateral sacro-iliac jointOrtho-Bechterew's test performed bilaterally. Patient indicated mild on the bilateral sacro-iliac joint .Ortho-Straight Leg Raiser Test performed. Patient indicated no pain bilaterally. Ortho-Kemp's Test performed. Patient indicated no pain bilaterally.Ortho-Braggards Test performed. Patient indicated no increase of radicular pain bilaterally.Ortho-Ely's Test performed bilaterally. Patient indicated mild pain on the left and right (equal) upper lumbar spine and sacro-iliac joint.Ortho-Nachlas' Test performed. Patient indicated no pain bilaterally.Ortho-Yeoman's test performed bilaterally. Patient indicated increased pain in the S.I. joint that was mild on the left and right (equal).

Assessment: ASSESSMENT:Brittany feels the complaint has improved her ability to OTHER and has changed about 70% since the onset of this complaint/condition. She has been evaluated by analyzing the OTHER functional outcome assessment tool with beginning score or percentage of 32 and goal score or percentage of 10% or better. The current overall score or percentage is 22 with an overall change of 10%. In consideration of the findings from today's re-evaluation of Brittany's complaints, the outcome score and my examination findings for this condition, continued treatment is necessary and the new treatment plan will be modified to decrease number of visits.Brittany is of good health and has made good progress and recovery with few residuals. She continues to haveno complicating factors and no noted as contraindications to chiropractic care, it is reasonable to believe that her recovery may take about the same length of time as an average patient with an uncomplicated case. DIAGNOSIS:Upon consideration of the information available the diagnosis has remained the same and is as follows: (S33.5XXA) Sprain of lumbar ligts, initial, (S39.012A) Strain of lower back, (M62.830) Muscle spasm of back, (M54.5) Low back pain, (M99.03) Seg and somatic dysf of lumbar reg, (M99.04) Seg and somatic dysf of sacral reg, (M99.05) Seg and somatic dysf of pelvic reg, (S29.012A) Strain of back wall of thorax, (M54.6) Pain in thoracic spine, (M99.02) Seg and somatic dysf of thoracic regDaily Assessment: showing improvement and meeting expectations as indicated in today's subjective.- Current Status: Improving because she is reporting less discomfort and is showing improved function.






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Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3,



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T7, T11, L2, L4 and left pelvis spinal level(s). ------- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:05. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 5:20.- Therapeutic Exercise: Static weight assisted Therapeutic Exercises performed as detailed in the initial treatment plan for 8 minutes. Exercise began at 5:20. Patient standing on easy balanced platform wit 3lb weighted resistance. Exercise completed at 5:28.- Therapeutic Exercise: Whole body vibration. Therapeutic Exercises were performed as detailed in the initial treatment plan for 5 minutes. Exercise began at 5:28. Each performed for 30 seconds. Bilateral calf stretch, bilateral hamstring stretch, bilateral hip flexor stretch, bilateral thoraco-lumbar lateral flexion, chair pose, foundation pose. Exercise completed at 5:33.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









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Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T4, T7, T11, L2, L5 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as mildly reduced with pain noted.








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today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T4, T7, T11, L2, L5 and left pelvis spinal level(s). ------- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 3:04. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3



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minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 3:19.- Therapeutic Exercise: Static weight assisted Therapeutic Exercises performed as detailed in the initial treatment plan for 8 minutes. Exercise began at 3:19. Patient standing on easy balanced platform wit 3lb weighted resistance. Exercise completed at 3:27.- Therapeutic Exercise: Whole body vibration. Therapeutic Exercises were performed as detailed in the initial treatment plan for 5 minutes. Exercise began at 3:27. Each performed for 30 seconds. Bilateral calf stretch, bilateral hamstring stretch, bilateral hip flexor stretch, bilateral thoraco-lumbar lateral flexion, chair pose, foundation pose. Exercise completed at 3:32.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









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Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T7, L2, L5 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as mildly reduced with pain noted.








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today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3, T7, L2, L5 and left pelvis spinal level(s). ------- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:20. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3



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Subjective: Objective: Daily Objective Findings:- Spinal Restriction(s)/Subluxation(s): T3, T6, T9, L2, L4 and left pelvis- Extraspinal Restrictions/Subluxations: ------. - Pain/Tenderness: mid-thoracic, lower thoracic, thoraco-lumbar, upper lumbar, lower lumbar, lumbo-sacral and sacral- Postural Analysis: short left leg (pelvic deficiency). - Muscle Spasm(s): moderate muscle spasms in the following areas; posterior cervical (neck), left trapezius, upper thoracic, right posterior trapezius, lower thoracic, lumbar, left sacroiliac, right sacroiliac and sacral. - ROM Concern(s): entire lumbar spine and thoracic extension was recorded as mildly reduced with pain noted.


Plan: TREATMENT PLAN:Brittany's treatment plan for this episode began on 1/21/2016 and is projected to be completed by 4/28/2016.- Home/Self Care: Brittany was instructed in home care recommendations that included: home cold pack issued today. She was instructed to ice for 20 minutes for pain, repeat after 60 minutes and discontinue after 3 hours- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Functional Deficit: Brittany reports employment has become difficult due to some or all of the following: bending over, climbing stairs, driving car, getting in/out of car, performing household chores, lifting objects, rising out of chair or bed, sitting and walking when she does this more than 3 minutes- Short Term Tx Goal: To increase her ability to perform the above to 30 minutes by the re-exam date within 30 days unless improvement warrants discharge sooner.- Long Term Goal: Attain pre-condition/pre-injury status






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- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) (approx: 18 to 24 visits) to the lumbar spinal region, lumbosacral spinal region, sacral spinal region, sacroliliac spinal region, thoracic spinal region and pelvic spinal region at a frequency and duration of 3 visits per week for next 4 weeks followed by a re-exam within 30 days.- Tx Effectiveness: Overall effectiveness of treatment for this complaint will be evaluated by analyzing the Low Back Disability Questionnaire (Revised) functional outcome assessment tool. The beginning score or percentage was 22 disability and the goal score or percentage is 10% or better.- Traction: Y-Axis mechanical traction applied to bilateral full spine to increase joint mobility during relief phase treatment. For 8 minutes 3 visits per week for next 4 weeks- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvic region(s) for 10 minutes with medium resistance band for 20reps - 3 sets to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activities during therapeutic phase treatment. For 10 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise-Patient consented: Manual stretching therapeutic exercises performed to the bilateral muscle group of the upper thoracic, muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar and muscle group of the pelvicregion(s) for 15 minutes for 2 reps - 2 sets to improve kinesthetic sense, to improve posture, to improve coordination, to improve proprioception for sitting activities and to improve proprioception for standing activitiesduring therapeutic phase treatment. For 15 minutes at a frequency and duration of 3 visits per week for next 12 weeks- Therapeutic Exercise: Whole body vibration therapeutic exercises were performed to the bilateral muscle group of the mid thoracic, muscle group of the lower thoracic, muscle group of the upper lumbar, muscle group of the lower lumbar, muscle group of the pelvic, muscle group of the upper leg and muscle group of the lower leg region(s) for 5 minutes for 1 reps - 1 sets to improve kinesthetic sense, to improve posture and to improve coordination during therapeutic phase treatment. For 5 minutes at frequency and duration of 3 visits per week for next 12 weeksROF- Consent: Before treatment was rendered a Report of Findings was presented. I reviewed with Brittanythe condition as I see it, the recommended treatment/schedule, options, relative risks, and financial obligations. All questions were addressed and Brittany expressed an understanding. At this time an Informed Consent was signed and treatment begins today.Today's Treatment:- Chief Complaint: mid thoracic, lower thoracic, left lumbar, lumbar, right lumbar, left sacroiliac, right sacroiliac and sacral- Primary Treatment: Diversified, Drop Table and Manual- Chiropractic Manipulative Therapy (CMT) to the T3, T6, T9, L2, L4 and left pelvis spinal level(s). ------- Therapeutic Exercise-Patient consented: Manual stretching Therapeutic Exercises performed as detailed in the initial treatment plan for 15 minutes. Exercise began at 5:32. Therapeutic wobble chair: 25 reps each of side to side, front to back, clockwise rotation, counterclockwise rotations. Cervical extension traction: 20 reps with 20 second hold on final rep- increase by 10 reps each week. Cervical/Lumbar extension traction stretch: 3 minutes. Beginner floor exercises: single knee to chest, both knees to chest, single knee to opposite shoulder, pelvic tilt, pelvic tilt with lift, cat/camel: each performed 2 times for 15-20 second hold. Precor stretchtrainer: lower back, upper back, shoulders, hips/gluteals: each performed 2 times for 15 seconds. Exercise completed at 5:47.- Therapeutic Exercise: Static weight assisted Therapeutic Exercises performed as detailed in the initial treatment plan for 8 minutes. Exercise began at 5:47. Patient standing on easy balanced platform wit 3lb weighted resistance. Exercise completed at 5:55.- Therapeutic Exercise: Whole body vibration. Therapeutic Exercises were performed as detailed in the initial treatment plan for 5 minutes. Exercise began at 5:55. Each performed for 30 seconds. Bilateral calf



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stretch, bilateral hamstring stretch, bilateral hip flexor stretch, bilateral thoraco-lumbar lateral flexion, chair pose, foundation pose. Exercise completed at 6:00.- Advised - Tx Effect: Treatment rendered without incident and responding as expected.- Next Visit: continue with treatment plan as scheduled









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Documents

Chart Notes - Vortala- Therapeutic Exercise: Resistance band assisted therapeutic exercises performed to the bilateralmuscle group of the mid thoracic, muscle group of the lower thoracic,