May 12, 2011
The Law Offices of Pearce, McPhee, and Pendleton
519 Keokuk Road
Suite 203
Mayberry, SC 49382
Attn: Mr. Opie Taylor
Re: Jones, John , Mr.
Date of Injury/Onset: December 24, 2010
Policy No: TK-3459629
Claim No: 849576739-e
Dear Mr. Taylor:
On May 9, 2011, Mr. John Jones presented himself for an initial examination and
evaluation of his complaints arising from a motor vehicle accident that he was involved
in on December 24, 2010.
I am sending this report to you as a professional courtesy because Mr. Jones is a
patient of yours and I would like to give you the opportunity to call if you have any
questions.
INJURY DESCRIPTION:
The time was 10:00:00 AM. Mr. Jones stated that he was the driver in a car which was
making a right turn at approximately 10 m.p.h. According to the patient, the other
vehicle involved was travelling at approximately 55 m.p.h. He stated that the other
vehicle struck his vehicle on the left rear side.
Mr. Jones also reported that, at the time of the accident, the road conditions were sandy
and visibility was fair. In addition, he stated the damage to his car was considerable
(totaled). The estimated damage to the patient's vehicle was $9,000.00. Damage to
the other vehicle was moderate. He also stated that he did not see the accident
coming, and therefore was not braced for the impact. Also, he was wearing his seat
belt and had his shoulder harness on. On impact, both the driver's and the front
passenger's air bags deployed, but no side air bags.
His car was equipped with headrests, his own headrest being even with the bottom of
his head at the time of the accident. He also noted that he had his head turned to the
right at the moment of impact. The patient's body struck the inside of his vehicle on
impact, "my head struck my door window." He lost consciousness for only for a few
seconds, as far as I know during the accident. According to the patient, the police
showed up at the scene. An accident report was filled out at that time.
INITIAL COMPLAINTS:
Immediately following the accident, the patient's main complaints included pain behind
his eyes, irritability, anxiety, stiffness in the neck, confusion, nervousness, headaches,
nausea, neck pain and dizziness. Following the accident Mr. Jones was taken by
ambulance to the hospital emergency room. X-rays were taken of his head, neck and
back, which revealed no signs of fracture, but some evidence of soft tissue inflamation..
The patient had no lab work done following the accident. Then Mr. Jones was treated
with ice and the application of a cervical collar. He was given a prescription for pain
meds subscription and released. On release he was given instructions to alternate ice
and heat on his neck and left shoulder.
CURRENT COMPLAINTS:
Mr. Jones's current signs and symptoms were assessed today. His first symptom is
dull, aching, throbbing, numbing and pounding right occipital headaches. He reported
that the pain radiates into both shoulders and both arms. It occurs between one half
and three fourths of the time when he is awake, and causes serious diminution in his
capacity to carry out daily activities. He further indicated the symptom is brought on by
bending to the right. It is aggravated by bending backward, twisting to the right and by
sneezing. Some relief is experienced by sitting.
Mr. Jones's second stated symptom is spastic, numbing and tingling pain in the mid
back on the left side. He stated that this symptom radiates into the left hip. It occurs
between one fourth and one half of the time when he is awake, is tolerated, but does
cause some diminution in his capacity to carry out daily activities. He further indicated
the symptom is brought on by bending forward. It is aggravated by bending backward.
Some relief is experienced by bending to the left and by sitting.
He stated his third symptom is dull, throbbing and pounding pain in the low back
bilaterally. He stated the pain is also stiffness. He stated that this symptom radiates
into both legs. It occurs between one fourth and one half of the time he is awake, and is
tolerated but it does cause some diminution in his capacity to carry out daily activities.
He further indicated the symptom is brought on by standing. It is aggravated by
coughing, sneezing and by straining. Some relief is experienced by sitting.
HISTORY:
Mr. Jones indicated that his current symptoms resulting from the aforementioned
accident/onset of December 24, 2010 appear to be a recurrence of previous, similar
complaints that were asymptomatic (dormant or healed) at the time of this more recent
accident/onset. He reported feeling well with none of his previous complaints present
just prior to this most recent accident/onset.
I have determined that Mr. Jones’s history has not contributed to his present condition.
His most recent prior similar symptoms occurred 5 years ago.
A careful radiographic examination of Mr. Jones‘s most recent x-rays has revealed a
pre-existing condition which has contributed to the current overall condition of the
patient, but the prior condition was asymptomatic at the time of the most recent accident
which occurred on December 24, 2010.
Social History:
Mr. Jones stated that he was out of work for one week, due to the motor vehicle
accident of December 24, 2010.
Prior Treatment Information:
The patient reported that prior to his first visit to this office, he saw Dr. Brad Newman,
whose specialty is orthopedic surgery. His first visit there was on July 6, 2010. X-rays
were performed at that time. During the 2 visits to that office, Mr. Jones received pain
killers and muscle relaxant, which he reported had little, if any, benefit. The patient is
no longer receiving treatments at that office. His last visit there was on July 20, 2009.
Treatment to date has been for the purpose of reducing symptoms and providing for
maximum regrowth and recovery.
During the initial, intensive care period following the accident, Mr. Jones was instructed
to apply alternating hot and cold compresses to the injured area.
ACTIVITIES OF DAILY LIVING ASSESSMENT:
Based on an assessment of Mr. Jones’s history, along with his subjective complaints,
objective findings, and other test results, it is evident from a standpoint of medical
certainty, that his current condition did result from the type of injury/onset described in
this report. He reported suffering varying degrees of losses of functional capacity with
the following activities:
With regard to Self Care and Personal Hygiene, Mr. Jones stated: combing his hair and
making his bed can be performed, despite significant pain, but only if he has help;
bathing, washing his hair and tying his shoes can be done without much difficulty,
despite some pain; putting on his shoes can be done without difficulty.
With regard to Physical Activity, Mr. Jones stated: standing and sitting can be done, but
not without some difficulty because of the resulting pain; reaching and bending to the
right can be performed without any problem.
Regarding Functional Activities, Mr. Jones stated: climbing stairs can be done without
much difficulty, despite some pain.
With regard to Social and Recreational Activities, he stated: golfing and dating can be
done, but not without some difficulty because of the resulting pain; dining out can be
performed without any problem.
Regarding Travel, Mr. Jones stated: driving a motor vehicle and riding as a passenger
for long periods can be done without much difficulty, despite some pain.
With regard to Communication, Mr. Jones reported the following: his ability to use a
computer or typewriter is moderately restricted by his condition; his ability to
concentrate is slightly affected by his condition.
With regard to Sensory Functions, he stated the following: his sense of taste and sense
of smell are mildly restricted by his condition.
With regard to Hand Functions, Mr. Jones reported the following: his ability to
discriminate things by touch is slightly affected by his condition.
Regarding Sleeping, he stated: his ability to sleep a normal, restful nights sleep is
moderately restricted by his condition.
With regard to Sexual Function, he stated: his ability to participate in desired sexual
activity is moderately restricted by his condition.
GENERAL PHYSICAL EXAMINATION:
Mr. Jones is a right-handed 60 year-old mentally alert and cooperative male.
Date of Birth: February 23, 1951.
His superficial appearance did not indicate any obvious distress. Minor's Sign was not
present, tending to rule out sciatica. An antalgic spine tilt on the left side was apparent
when he stood upright. Gait: On ambulation, he revealed an antalgic gait, apparently
favoring the left side.
Weight: 180.00 pounds. Stature: Average build. Height: 10 feet 2 inches. Body
temperature: 99.0 degrees Fahrenheit;(normal).
Blood Pressure (Left Side): 125/85 mm Hg. On the left side, Mr. Jones's blood
pressure measurement indicated a high normal.
Blood Pressure (Right Side): 130/95 mm Hg. On the right side, Mr. Jones's blood
pressure measurement indicated a mild hypertension.
Pulse Rate (resting): 85 beats per minute (normal). Heart: No arrhythmia or
murmurs were noted. Lungs: No rales, rhonchus or wheezing were noted in any of the
lobes of the lungs. On examination, the eyes, ears and throat appeared normal.
Deep Tendon Reflexes: The left Biceps and left and right Triceps tendons presented a
normal reflex. Hyper-reflexia was noted in the right Biceps and left Brachioradialis
tendons.
RANGE OF MOTION STUDIES:
The following joint range of motion calculations and analyses were performed to
determine Mr. Jones’s present condition with regard to joint motion.
The following measurements were obtained utilizing an inclinometer.
Cervical Spine:
Angle
Analysis
Flexion
45 degrees
Slight restriction: norm is 50
degrees.
Extension
58 degrees
Slight restriction: norm is 60
degrees.
Left Lateral Flexion
45 degrees
No restriction: norm is 45 degrees.
Right Lateral Flexion
44 degrees
Slight restriction: norm is 45
degrees.
Left Rotation
75 degrees
Slight restriction: norm is 80
degrees.
Right Rotation
79 degrees
Slight restriction: norm is 80
degrees.
Thoracic Spine:
Angle
Analysis
Extension (Angle of
Minimum Kyphosis)
48 degrees
No restriction: norm is 0 to 59.
Flexion
49 degrees
Slight restriction: norm is 60
degrees.
Left Rotation
27 degrees
Slight restriction: norm is 30
degrees.
Right Rotation
29 degrees
Slight restriction: norm is 30
degrees.
Lumbar Spine:
Angle
Analysis
True Lumbar Flexion
58 degrees
Moderate restriction: norm is 60+, if
S1 is 45+.
T12 Flexion
103 degrees
S1 Flexion
45 degrees
True Lumbar Extension
T12 Extension
S1 Extension
28 degrees
48 degrees
20 degrees
L. Straight Leg Raise
R. Straight Leg Raise
65 degrees
68 degrees
Exceeds norm: norm is 25 degrees.
The Straight Leg Raising angle on the tightest side (65 degrees) is within 15 degrees of
the total hip motion (S1 Flexion plus S1 Extension), which is 65 degrees, thus validating
the Lumbosacral flexion and extension test results.
Left Lateral Flexion22 degreesSlight restriction: norm is 25 degrees.
Right Lateral Flexion
26 degrees
Exceeds norm: norm is 25 degrees.
KINESIOLOGICAL STUDIES:
The following muscles were tested to determine if there were any nerve related motor
deficits, utilizing the following scale:
Grade 5 Active movement against gravity with full resistance.
Grade 4 Active movement against gravity with some resistance.
Grade 3 Active movement against gravity only without resistance.
Grade 2 Active movement with gravity eliminated.
Grade 1 Slight contraction and no movement.
Grade 0 No contraction.
Upper Extremities:
Left Shoulder:
The left Infraspinatus was weak (Grade 4).
The Rhomboid muscle group, Levator Scapulae and Supraspinatus were very weak
(Grade 3).
Right Shoulder:
The right Infraspinatus was strong (Grade 5).
The Rhomboid muscle group, Levator Scapulae and Supraspinatus were weak (Grade
4).
Lower Extremities:
Left Hip:
The left Psoas Major and Iliacus group was weak (Grade 4).
The Sartorius was very weak (Grade 3).
Right Hip:
The right Psoas Major and Iliacus group was strong (Grade 5).
The Sartorius was weak (Grade 4).
Grip Strength Evaluation:
The following measurements were obtained using a Jamar Dynamometer. Three
readings of the involved hand are averaged and compared to those of the opposite
hand, which is usually normal.
Left Hand:
Right Hand:
31.29, 27.21, 26.30
69.00, 60.00, 58.00
22.22, 24.04, 24.94
49.00, 53.00, 55.00
Avg:
Avg:
Avg:
Avg:
28.3 kilograms.
62.3 pounds.
23.7 kilograms.
52.3 pounds.
Utilizing a 'Strength Loss Index' formula, which is Normal Strength minus Abnormal
Strength divided by Normal Strength equals % Strength Loss Index:
Left Hand: (46.3 - 28.27) divided by 46.3 = 38.95% Strength Loss Index.
Right Hand: (46.3 - 23.73) divided by 46.3 = 48.74% Strength Loss Index.
NEUROLOGICAL EVALUATION:
Peripheral Nerve Tests:
The Biceps Reflex, which when lacking can indicate an upper and lower motor neuron
lesion, and a lack of integrity of the afferent and efferent fibers of the Musculocutaneous
Nerve, was negative on the left side. In this test the patient is seated with the forearms
resting on the thighs. The examiner places the biceps tendon under slight tension by
placing his or her thumb over the center of the tendon. Using a percussion hammer, the
examiner strikes his thumbnail, observing and feeling the flexion of the elbow and
contraction of the Biceps Muscle which normally results.
The Brachioradialis Reflex, which when lacking can indicate a lack of afferent and
efferent integrity of the Radial Nerve in relation to an upper or lower motor neuron
lesion, was negative on the left side. This reflex is tested with the seated patient's
forearms resting on the thighs with the thumbs facing up. While palpating the belly of
the Brachioradialis, the examiner strokes its tendon with a reflex hammer at its point of
maximum response. In a true brachioradialis stretch reflex, only the forearm will flex.
The Infraspinatus Reflex, which when negative indicates a lack of integrity of the
C5/C6 nerve roots and the Suprascapular Nerve, was abnormal. This reflex is tested
with the patient seated. The examiner strokes the area over the scapula with a reflex
hammer at a point that’s on a line that bisects the angle formed by the spine of the bone
and its inner border. A normal reflex would be external rotation of the arm along with
extension of the elbow.
The Radial Reflex was abnormal.
Lumbosacral Nerve Tests:
The Heel-Walk Test, which when positive is indicative of a lesion of the fibers of the L5
Nerve Root, was positive. The patient is told to walk on the heels several steps forward,
then back the same way. If the patient has low back complaints and is unable to
perform this action because of either pain or weakness, the test is considered positive.
The Quadriceps Reflex was abnormal on the left side.
Sensory Deficit Testing:
The following sensory information was obtained utilizing a pinwheel and pressure.
There was pain, which is forgotten during activity, noted on the left side at the
dermatome zone of the Brachial Plexus from C5 through C8 and T1, which covers the
entire surface of the upper extremities.
There was also hypoesthesia, which interferes with activity, noted bilaterally at the T1,
T2 cutaneous zone of the Intercostobrachial and Medial Brachial Cutaneous, which is
on the anteromedial surface of the arm (with intercostobrachial).
ORTHOPEDIC EVALUATION:
Cervical Lesion Tests:
The Cervical Distraction Test, which indicates nerve root compression, was positive
on the left side. While seated, the patient actively rotates the head and neck until
radicular pain is produced. The examiner then rotates the head to the same extent but
with strong upward traction added to the motion. If this action performed by the
examiner gives relief or significantly reduces the patient's cervical and/or radicular pain,
this test is considered positive, indicating nerve root compression. If the patient can't
actively rotate the head or neck because of pain, the examiner can still do this test by
adding traction with or without rotation.
The Jackson Compression Test, which indicates nerve root compression, was
positive on the left side. In this test, the patient, sitting upright, attempts to laterally flex
the neck and head toward the affected shoulder. Then the examiner exerts downward
pressure with clasped hands on top of the patient's head. The test is positive if this
action exacerbates the patient's cervical and/or radicular pain indicating nerve root
compression.
The Maximum Cervical Compression Test, which indicates cervical nerve root
compression, was positive on the left side. In this test, the patient, sitting upright,
attempts to laterally flex the neck and head toward the affected shoulder. Then the
examiner directs the patient to bring the chin as close as possible to the shoulder. The
test may be repeated passively if there is no response when the patient does the action
actively. The test is positive when the action causes radicular pain on the side of the
flexion and rotation.
A positive test reveals cervical nerve root compression in that the action narrows the
diameters of the intervertebral foramina as much as anatomically possible.
The Shoulder Depression Test, which usually indicates adhesions of the spinal roots,
the adjacent structures of the shoulder joint capsule, or the dural sleeves, was positive
on the left side. This test is done with the patient supine. The examiner standing at the
head of the patient, flexes the neck to the side opposite to the shoulder being tested
while pushing the shoulder caudadward. Then, while maintaining the depression of the
shoulder, the head is rotated, again to the side opposite to the shoulder being tested. If
radicular pain is either produced or aggravated by the first action and then confirmed by
the second, the test is considered positive.
Thoracic Lesion Tests:
Forestiers Bowstring Sign, which is used to determine the existence of Ankylosing
Spondylitis (Marie-Strumpell’s Disease), was present on the left side. In this test, the
patient performs lateral bending while in a standing position. If there is ipsilateral
tightening and contracture of the paraspinal muscles instead of the contralateral side
tightening, the sign is considered to be present.
Lumbar Lesion Tests:
Goldthwait's Sign, which is used to differentiate between sacroiliac and lumbosacral
involvement, was present on the left side. When performing this test, if pain is brought
on before the lumbosacral joint is opened and it's possible to raise the leg on the
unaffected side to a greater level than the limb on the affected side without pain, then a
lesion of the sacroiliac joint or ligaments is presumed. When no pain is experienced
until the lumbosacral movement occurs and pain is felt when either leg is raised to
approximately the same height, which was the case with Mr. Jones, then a lumbosacral
lesion is more likely. This test is performed with the patient supine. The examiner
palpates the lumbosacral joint while slowly straight leg raising the limb on the affected
side. The test is then repeated on the unaffected side.
Smith-Peterson Test, which is used to diagnose and differentiate between sacroiliac
and lumbosacral lesions, was positive on the left side. When performing this test, if pain
is brought on before lumbosacral movement, then the test is positive for a sacroiliac
condition. However, if pain begins after lumbosacral movement occurs, then a
lumbosacral or sacroiliac lesion may be present. If the lesion is sacroiliac, the leg on
the opposite side can be brought higher without pain. If the lesion is lumbosacral, the
pain comes on when both legs are at the same height, which was the case with Mr.
Jones. The test is done by the examiner palpating, with one hand, movement of the
lumbosacral spine of the supine patient, while straight leg raising each leg with the other
hand. When there is acute inflammation, motion is more restricted toward the affected
side, whereas the opposite is true with a sacroiliac strain.
Sciatic Nerve Lesion Tests:
The Lasegue (Straight Leg Raise) Test was positive on the left side. On this patient,
moderate pain at T11-S1 was elicited at 80 degrees, . This test is done with the patient
supine and with the knee in extension. The examiner, actively flexes each thigh slowly
while holding the other hand on the knee to prevent its flexion. The leg is lifted 90
degrees or until pain prevents further motion. The final angle of flexion at which pain
occurs, as well as the location and intensity of the pain are noted by the examiner. This
test is considered positive when the straight leg cannot be raised to 90 degrees without
pain.
Intervertebral Disc Syndromes:
Kemp's Test, which usually confirms fracture, facet syndrome, or disc involvement, was
positive on the left side. This test can be done with the patient standing or sitting.
While stabilizing the pelvis, the patient's shoulder is firmly forced obliquely backward,
downward and medialward. The idea is to put the lower spine on the opposite side to
the one being tested, into a combined position of rotation, lateral bending, and
extension. The test is considered positive when low back pain radiates into the lower
extremity.
Miscellaneous Soft Tissue Lesion Tests:
Hueter’s Fracture Sign was present.
Hip Lesion Tests:
Ely's Heel to Buttock Test was positive bilaterally. When this test is positive, it is
usually indicative of one of the following: inflammation of the lumbar nerve roots, the
presence of lumbar nerve root adhesions, or a hip lesion. Laguerre's Sign was present
bilaterally. When this sign is present it is indicative of either a hip joint lesion, an
iliopsoas muscle spasm or a sacroiliac lesion, while ruling out a lumbosacral lesion.
Circulatory Disorder Tests:
Wright's Test was positive.
PALPATION EVALUATION:
Palpation, which is an examination using the hands, was performed to evaluate Mr.
Jones's response to pressure and to examine tissue consistency.
Paraspinal Studies:
Palpating the left paracervical muscles revealed moderate pain, mild edema, and
articular fixations.
Cervical region examination revealed the following: moderate pain, and mild edema at
C4.
Palpation of the left upper thoracic group of the dorsum disclosed moderate pain,
hypertonicity, and active trigger points. The mid thoracic midline structures
demonstrated slight pain and tenderness, mild edema, and mild myotonia.
X-RAY STUDIES:
Date of Study: May 9, 2011
The following films were available for review:
Cervical Spine:
Anterior-Posterior
Lateral
Oblique
Atlas-Axis (Odontoid Spot)
Thoracic Spine:
Posterior Adjacent
Lateral Upright
Lumbar Spine:
Lateral Upright
Left Oblique
Radiographic Analysis:
There is no evidence of fractures, gross osseous pathology, significant anomalies,
developmental distortions or pathological calcinosis present. Also, the facet joints
appear normal and the joints of Luschka (Uncinate processes) appear intact.
When the spinal column is viewed as an integral, contiguous structure, the vertebrae
present with moderate subluxation (misalignment) at C2/C3. Also presenting with
moderate subluxation is the vertebrae at T5-8. In addition, there appears to be no
misalignment or subluxation at L4-S1.
There is a moderate (Grade II) retrospondylolisthesis, indicating a sprain or disruption of
the anterior longitudinal spinal ligament, involving the vertebrae at L5/S1.
Motion Studies:
The relative movements of the vertebrae were evaluated utilizing extension and flexion
radiographs.
In extension, there was slightly excessive movement atExtremely excessive movement
was also noted at
In flexion, there was extremely excessive movement at
ASSESSMENT/DIAGNOSIS:
It is expected that Mr. Jones will experience favorable results from his treatments.The
patient is not yet at MMI and is presently receiving medically necessary therapeutic
care. Since his last visit, the patient has experienced some improvement.
Traumatic insult to the cervical spine with resultant brachial radiculopathy.
Hyperextension-hyperflexion injury to the cervical spine, accompanied by the usual
sequela of inflammatory reaction to paravertebral soft tissues.
307.81
346.2
719.0
721.2
721.3
Tension headache
Cluster headache
Cervical Facet Joint Swelling
Thoracic spondylosis without myelopathy
Lumbosacral spondylosis without myelopathy
PROGNOSIS:
The prognosis for Mr. Jones is good at this time. His is a somewhat complicated case
and despite the possibility of permanent residuals, continued improvement is expected.
TREATMENT:
Today's Modalities & Procedures: Following were the modalities used and/or
recommended today: home exercises, massage therapy, diathermy, spinal
manipulation and resistive exercises.
The above was for the purpose of increasing range of motion, increasing the ability to
perform normal activities of daily living and achieving maximum medical improvement.
FUTURE CARE PLAN:
Present Care Phase: As of today's visit, Mr. Jones is in a therapeutic phase of care.
Future Treatment Plan: Our future care recommendations include lumbar traction,
spinal manipulation and corrective spinal exercises two times a week for six weeks.
Goals of Treatment Plan: The preceding treatment plan has the goal of retarding
degeneration, correcting muscle imbalance and achieving maximum chiropractic
improvement.
CLOSING COMMENTS:
Many medical doctors have found that chiropractic care is a very effective option for the
handling of a number of structural problems underlying various patient complaints. If
you would like further information regarding Mr. Jones or chiropractic care in general,
please feel free to contact me.
Sincerely,
Peter C. Smith, D.C.