Patient: Tom Drake
Examined by: Heal Rehab Clinic and Spa
Diana Vasconcelos
Oct.10.2012
416-345-3456
dianavasconcelossmt.weebly.com
Amica Family Insurance
4563 Bathurst Ave
905-345-6545
MEDICOLEGAL REPORT
On October 10th 2012 Tom Drake arrived at the Heal Rehab Clinic and Spa for a rehabilitation
treatment; his chief complaint was of piriformis syndrome. Mr. Drake cannot drive for more
than 20mins without experiencing sharp pain in his lower back and right leg. He has come in
with quite a few impairments, mainly decreased range of motion and trigger point in piriformis.
I have summed up short outcomes of care and long term outcomes of care for Mr. Drake.
Consent was obtained from Mr. Drake prior to the assessments, reassessments, and treatments
and in order to release this information.
Impairment Levels
Mr. Drake is suspected to have left sciatic nerve compression by the piriformis muscle which is
causing pain and altered sensations down the right gluteal and posterior lower leg into his foot.
There is tenderness in the gluteals, trigger points in piriformis, and hypertonicity in
iliopsoas, quads and quadratus lumborum. He has decreased active range of motion in the
lumbar region with only 75% of flexion and pain when returning from flexed position; he has
decreased active, passive and resisted range of motion in the hip for internal rotation (pain and
weakness for RROM) as well as, decreased flexion (tight hams.) with mild pain (no hams.
involvement). During the postural assessment I found that Mr. Drake has postural misalignment
on the external rotators of the foot, excessive L-spine lordosis and forward head carriage.
Mr. Drake was also tested positive for Ataxic gait and he has a restricted right SI joint.
Outcomes of Care
The outcomes of care for the short term treatment (2x 45mins tx/wk for 2 wks= 4tx.) will be to
release trigger points in the piriformis muscle; decrease hypertonicity in iliopsoas, quads, and
quadratus lumborum; decrease tenderness in gluteals; mobilize restricted left SI joint; increase
restricted range of motion in the leg; restore muscle balance to improve postural mailalignment
and to improve his gait.
Pg. 1-2
Patient: Tom Drake
Examined by: Heal Rehab Clinic and Spa
Diana Vasconcelos
Oct.10.2012
416-345-3456
dianavasconcelossmt.weebly.com
Amica Family Insurance
4563 Bathurst Ave
905-345-6545
The outcomes of care for the long term treatment of 8tx over 6 weeks will be to enable Mr.
Drake to drive for 1 hour without pain, to provide remedial exercises that can alleviate pain felt
in certain positions and to educate client on posture and ergonomics, to decrease aggravating
factors.
Treatment Plan
Based on my findings the techniques that will be most beneficial for Mr. Drake will be to do
effleurage, specific compression, broad contact compression, stripping, passive stretch, gentle
PNF, fascial spreading, petrissage and joint mobilisation; a thermaphore will be used on the
gluteal region. Active range of motion, passive stretch, resistance exercises and strengthening
exercises will be used for the hip and piriformis.
This treatment plan will help with decreasing hypertonicity, increasing muscle and pliability in
gluteal region; releasing trigger points, restoring normal muscle resting tension, decrease sciatic
nerve compression; restoring normal range of motion, strengthening exercises to improve
piriformis function and core strength to support L-spine and pelvis; to also normalize
agonist/antagonist relationship to improve muscle endurance and structural support.
Conclusion
This treatment will be beneficial for Mr. Drake; we will work within a short-term treatment plan
and then move into a long-term treatment plan. If after the short-term reassessment the pain
pattern has not changed, a referral to an MD or osteopath will be made. After the 8 weeks I will
discontinue, change or continue with the treatment if necessary. Consent was obtained from
Mr. Drake prior to the assessments, reassessments, and treatments and in order to release this
information.
Pg. 2-2