Date of Accident: July 26, 2023

Initial Examination Findings:

• Pain and stiffness in the neck, especially with rotation and side-bending
• Muscle tightness and tenderness in the neck and shoulders
• Limited range of motion in the neck and upper back
• Possible misalignment of the vertebrae in the neck and upper back

Goals of Treatment:

• Reduce pain and inflammation
• Restore normal range of motion in the neck and upper back
• Improve muscle flexibility and strength
• Prevent chronic pain and disability

Treatment Plan:

Phase 1: Initial Intensive Care (Weeks 1-4)

• Frequency: 3 visits per week
• Chiropractic Adjustments:
  • Diversified technique for spinal alignment
  • Thompson Drop technique for gentle adjustments
  • Activator method for low-force adjustments
• Bodywork:
  • Trigger point therapy for muscle knots and tension
  • Myofascial release for improving soft tissue mobility
  • Instrument-assisted soft tissue mobilization (IASTM) to break up scar tissue
• Therapeutic Exercises:
  • Range of motion exercises for the neck and shoulders
  • Isometric neck strengthening exercises
  • Stretches for the neck, shoulders, and upper back
• Modalities:
  • Ice therapy for pain and inflammation reduction
  • Electrical stimulation for pain relief and muscle relaxation
  • Ultrasound therapy for deep tissue heating and increased blood flow

Phase 2: Rehabilitation (Weeks 5-12)

• Frequency: 2 visits per week
• Continuation of chiropractic adjustments and bodywork with emphasis on restoring proper movement patterns
• Progression of therapeutic exercises to include dynamic stretching, strengthening, and proprioception exercises
• Introduction of ergonomic education to prevent future injury
• Evaluation of patient's progress and modification of treatment plan as needed

Phase 3: Maintenance (Weeks 13+)

• Frequency: 1 visit per month or as needed
• Periodic chiropractic adjustments to maintain spinal alignment
• Continued therapeutic exercise program for long-term pain management and prevention of re-injury
• Lifestyle recommendations for overall health and wellness

NOTES: Customer has progressive insurance.