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2. Prognosis

3. As a result of the previously mentioned accident the patient has an altered ligamentous structure in that although it has healed it is less than optimal. When ligaments are torn, as in {'title'} {'l_name'}, the body replaces a rather neat, organized network of a combination of yellow elastic, and dense white nonelastic collagen fibers, with a rather haphazard array of dense white connective scar tissue. This scar tissue helps hold bones together, but doesn't have the resiliency that the original connective tissue had. It causes a loss of range of motion at the joint level and therefore increases the stress upon that joint. The joints above and below that joint are also stressed to a greater degree since they must compensate for the loss of motion of the injured joint.
4. The injury to the spine resulted in a stretching and tearing of the paraspinal ligaments. These ligaments are a combination of white and yellow fibers. The yellow fibers are more specialized a fiber and are more elastic, and allow more flexibility than the white. Since the white is produced at a greater rate than the yellow the normal yellow/white ratio is thrown off resulting in a less than optimum ligament. The increased amount of white fibers results in a scar formation within the ligament.
5. The resultant \"scarred\" ligament does not have the same resiliency as a normal ligament and results in a greater amount of stress at the level of the injured joints and at the level of the joints above and below the injury, because those joints must now compensate for the loss of function of the involved joints.
6. The trauma to the spine has caused a general weakening of the soft tissue structure. The ligaments involved have become over stretched and torn giving rise to, even in its healed state, spinal instability. This unstable condition allows the vertebral motor units to be somewhat hypermobile. They are more prone to reinjury, even slight trauma, which otherwise would have caused no incident, may cause muscular splinting to occur.
7. Muscular splinting is a term given to muscles which have gone into spasm to act as a restrictive agent, like a natural cast. This natural cast is formed to restrict motion of the spine and to protect the spine from further injury. Chronic muscular splinting or spasming may lead to myofibrositis.
8. Myofibrositis has occurred in the above mentioned areas in this patient. The long-term effects of myofibrositis may include calcification of the damaged muscular tissue. This would obviously cause a loss of function in the muscle and would result in pain and discomfort.

9. Arthritis

10. Mild arthritic changes are expected as a result of these injuries.
11. According to Wolf's law, the above described joints are likely to become arthritic since calcium infiltrates areas of stress.
12. It is well documented that strain and sprain type injuries to the spine cause post-traumatic osteoarthritis. In view of this, the degree of post-traumatic pathology will be more severe in this particular patient. {'title'} {'l_name'} will, therefore, continue to have occasional flare-ups of his/her symptomatology and this will be proportionate to his/her activity.
13. There is also the possibility of discovering more unfavorable developments in the future.

14. Intro to exacerbations

15. While the treatment has been remarkably effective in the treatment of this patient there are some residuals which will undoubtedly give {'title'} {'l_name'} periodic grief.

16. Exacerbations

17. Through Chiropractic manipulation and treatment of this patient an attempt was made to restore normal function to the involved joints, and I feel we have succeeded fairly well in this endeavor, especially considering the initial amount of injury. However, I can say with certainty that the involved ligaments are not \"as good as new\" and that {'title'} {'l_name'} may expect to have periods of exacerbations of pain and stiffness in the involved joints.
18. This patient has made sporadic improvement, obtaining progressive general relief of symptoms. However, these type injuries are subject to episodes of remission and exacerbations caused by various aggravations. Although pain and discomfort ease after each visit, they recur necessitating the use of a cervical collar/lumbo-sacral support at times. And I have instructed {'title'} {'l_name'} to use the above mentioned support at the his/her own discretion.
19. It is felt, considering the patient's symptomatology, results of comparative tests and examinations, and past experience with similar cases, that this weakness will predispose the patient to further problems in the injured area from aggravation or trauma which might not have otherwise bothered him/her prior to the accident.
20. Due to the nature of the injuries traumatically induced and the reduced functional capacity manifested as a result. It is likely that the areas of injury may remain areas of greater risk of future trouble from aggravation and trauma which may not have had the same effect prior to the accident.
21. It is a common observation in cases such as these to see remissions and exacerbations for no apparent external reason. Due to a structural weakening of the spinal column, traumatically induced, {'title'} {'l_name'} can anticipate future recurrence of the pain and discomfort from time to time, especially prevalent at times of stress, fatigue or emotional upset. There is little anyone can do to prevent this.
22. Remissions and exacerbations of complaints on an alternate basis are quite prevalent following injuries of this nature. Symptoms may remain dormant for some period of time only to resume through insidious onset.
23. {'title'} {'l_name'} is responding to treatment. However, due to the nature of the injuries traumatically induced and the reduced functional capacity manifested as a result, it is likely that the areas of injury may remain areas of greater risk of future injury. This weakness will predispose those areas to further trouble from aggravation and trauma, which may not have had the same effect prior to the accident.

24. Muscle spasm

25. Muscle spasms are a recurrent problem for {'title'} {'l_name'}. Treatment has been effective in reducing the severity of the spasms, and the number of muscle fibers involved, but the fact that they persist, indicates the injuries are of a permanent nature.
26. Muscle spasms and persistant trigger points point to a poorer recovery for {'title'} {'l_name'}.
27. Muscle spasms affect {'title'} {'l_name'}'s activities and lifestyle. he/she has had to alter the way he/she does things so as not to aggravate he/she pain and symptoms.
28. Nerve root compression has caused radicular pain. The subsequent pain causes muscles supporting the injured area to go into spasm and to splint in an effort to immobilize the area and relieve pain, in addition to acting as a protective mechanism to keep the area from further possible aggravation and re-injury.

29. MRI Findings... ADL

30. This patient had been a very active person. The injuries he/she sustained, particularly the disc injury certainly reduced the quality of his lifestyle. (Please see the attached MRI Report) As a result of the previously mentioned injury, {'title'} {'l_name'} must severely limit or restrict his activities, so as not to exacerbate his/her condition.
31. Exacerbation and remissions are common and may be provoked by ordinary activities of daily living. Precipitating factors are muscular exertion and/or increased muscular activity. {'title'} {'l_name'} will have intermittent discomfort in he/she neck and back areas in the future.

32. Ortho neuro ROM etc...

33. The patient continued to make progress in that the most recent examination indicated that all or most of the orthopedic tests were negative for pain, however he/she continues to have neurological involvement as a permanent consequence of his/her injuries.
34. The positive neurological and orthopedic findings, along with the positive X-ray findings, and his/her loss of range of motion and symptomatology, point to a poor recovery.
35. The persistence of motion and mobility alteration of the (cervical and/or lumbar) spine indicates the relative permanency of the residual kinetic disturbance. This is characteristic of actual sprain-type injuries if the ligamentous tissues have been torn, as is apparent in this case.
36. It is my opinion that {'title'} {'l_name'} remains unstable and will not be able to return to his/her previous type of employment. I recommend vocational rehabilitation and further treatment until he/she reaches a permanent and stationary status. It is strongly recommended that he/she work in a vocation that will not exacerbate his/her symptomatology.

37. Prognosis List

38. While the orthopedic tests performed on {'title'} {'l_name'} were essentially negative for pain on the final examination, it has been documented he/she has had continued pain and an altered lifestyle as a result of the previously described injuries.
39. Please see the attached affidavits of daily living.
40. The final examination revealed that the {'title'} {'l_name'} has responded well to treatment.
41. The final examination of {'title'} {'l_name'} indicates chiropractic care has been an effective mode of treatment.
42. He/She continues to have pain and discomfort at the sites of injury in spite of all efforts to minimize the effects of the injury.
43. The cervical spine, which received the major trauma of the impact, will most likely be predisposed to an accelerated rate of degenerative joint disease.
44. It is likely that {'title'} {'l_name'} will experience episodes of pain in the future as a result of residual unresolved injuries.
45. Healing of an injury of this type will typically result in adhesions and scarring of the injured areas, and consequently the normal degenerative processes of the spinal column associated with aging are prematurely accelerated. This often results in localized chronic pain, most prevalently with changes in weather, times of stress, fatigue or overexertion.
46. {'title'} {'l_name'} 's response to treatment has been gratifying at times and disappointing at others. We have usually been able to relieve his/her symptomatic complaints on an immediate basis, but we have not been able to stop all of them from recurring.
47. Comparative examinations, including X-rays, should be made periodically to evaluate his/her improvement and to determine the actual degree of post traumatic pathology and disability, if any.
48. {'title'} {'l_name'} has made continual improvement, obtaining progressive general relief of his/her symptoms.

49. Further Care Necessary

50. This patient exhibits neurological deficits, which must continue to be monitored. The growth and healing rate of an injured nerve is the slowest of all body cell types. And the function of a nerve may be restored up to two years after an injury, i.e.; permanency may not be fully determined until after 2 years in most cases.
51. Progress for {'title'} {'l_name'} has been slow but constant. The present course of treatment should continue for another six to eight weeks, at which time a re-evaluation can be made regarding his/her condition and the future course of treatment.
52. Although {'title'} {'l_name'} has progressed well under the present mode of treatment, he/she still continues to exhibit symptoms. This is due in part to the normal healing process, with scarring and localized inflammatory reactions at the site of the injuries causing discomfort.
53. Based upon his/her response to the treatment, and given his/her present symptomatology, I do not feel that the point of maximum medical improvement has been reached. With this in mind, treatment should be continued.
54. {'title'} {'l_name'} has shown continued progress, however his/her condition is not yet permanent and stationary. I anticipate that he/she will need to remain under care for at least another __________, at which time a re-evaluation can be made to determine the extent of the injuries.
55. {'title'} {'l_name'} has progressed well under the current regime of treatment, however it is recommended that he/she continue treatment for another thirty to sixty days, at which time a re-evaluation can be made as to the need for future treatment.
56. {'title'} {'l_name'} has been receiving treatment and therapy in our office _____times a (week/month) since the accident, and he/she relates that his/hersymptoms have improved since the injury.
57. In view of this, and to facilitate the healing process, I plan to keep {'title'} {'l_name'} under treatment and observation for a minimum of ______ days. Assuming there is no further aggravation of the symptoms, this will be done on a continued reduction of frequency basis.
58. {'title'} {'l_name'} has been responding very well to treatment. I feel that his/herprogress should continue, and barring any future traumas to the injured areas he/she should be asymptomatic within thirty to sixty days.
59. It is anticipated at this time that {'title'} {'l_name'} is ready to be treated only once per week, possibly twice per month. If the present rate of response continues, he/she should reach maximum medical improvement in approximately thirty to sixty days.
60. The prognosis for {'title'} {'l_name'} is favorable. However, due to the fact that a complete correction of the postural attitude has not been attained, he/she should continue with manipulative spinal corrective care on a periodic basis. This is not only to support the positive changes that have taken place thus far, but also in an attempt to continue the corrective process.
61. I am unable at this time to give an accurate prognosis in duration of care, but I do believe that the healing prognosis for {'title'} {'l_name'} is good.
62. It is felt that the patient has reached a plateau in the effects of treatment at this time however it has been noted that if the patient breaks in the regular routine of treatment the symptoms return and at a much greater level of pain and discomfort. I therefore recommend that this patient be seen on a bimonthly basis to help ameliorate the patient's symptoms. Treatment on such a limited basis cannot be construed as \"Maintenance therapy\" for it is truly a palliative measure.

63. Reached MMI

64. Considering the patient's lack of response to any further Chiropractic treatment and/or any other therapies applied for the benefit of this patient it is my opinion that this patient has reached Maximum Medical Improvement and should be released from further care.
65. {'title'} {'l_name'} has made improvement in both reduction of cervical spine pain as well as an increase in cervical spine range of motion. He/She also relates the fact he/she is sleeping better, concentrates better and now has pain on a periodic instead of a constant basis. These findings are very consistent with a traumatic ligamentous injury to the cervical spine resulting in mild instability.
66. It is the opinion of this clinic that {'title'} {'l_name'} has reached maximum medical improvement. Although symptomatology has been reduced at this time, he/she will continue to experience minimal to moderate pain when engaging in any activity. Any future trauma to his/her spine could predispose him/her to complications that could be irrevocable.
67. I was delighted to have had the opportunity to accomplish structural correction for {'title'} {'l_name'} . Because of the success of these corrections his/her health problems arising in the future related to the specific injuries have now been greatly reduced from what they potentially could have been.

68. Recovery... Prognosis...

69. A full recovery is expected, but some preclusion\'s are anticipated.
70. I believe that {'title'} {'l_name'} will experience an uncomplicated recovery, with no residuals.
71. {'title'} {'l_name'} should seek attention on an as needed basis to reduce any future symptomatology.
72. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} can be considered excellent.
73. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} can be considered good.
74. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} can be considered good, but with possible residuals.
75. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} is generally favorable.
76. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} is favorable, with residuals.
77. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} is fair.
78. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} is fair, with residuals.
79. I still believe his/her condition to be of a relatively serious nature.
80. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} is guarded.
81. At this point in time, it is my opinion that the prognosis for {'title'} {'l_name'} is poor.
82. In my opinion, the above described injuries are causally related to the above described accident.
83. In my opinion, the above described injuries are causally related to the above described accident and the residual altered soft tissue structure is permanent in nature with a resultant permanent consequential limitation of use of his cervical and lumbar spine.
84. Due to the residual altered soft tissue structure which is permanent in nature there is a resultant permanent consequential limitation of use of his/her cervical and lumbar spine.