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.