Exam Date: February 5, 2004

Examined by: David L. Johnson, D.C.

Mrs. Martin's cervical curve was determined to be moderately decreased. In a resting posture, Susan's head is tilted to the right.

ORTHOPEDIC EXAMINATION

The following findings were obtained during an active and estimated cervical range of motion evaluation.

February 5, 2004-ROM findings:
Flexion (Flex) 30
Extension 25
Rt Rotation 65
Lft Rotation 60
Rt Lat Flex 30
Lft Lat Flex 35

Susan indicated that she experienced pain during flexion in the right superior cervical region. During extension, Susan indicated that she experienced pain in the right superior and inferior cervical region. During left lateral flexion, Susan indicated that she experienced pain in the left and right cervical region.

A Cervical Compression test was positive and produced pain in the right cervical region, the left cervical region, and the upper thoracic region.

A Foraminal Compression test (with the head tilted to the right) was positive and produced pain in the right cervical region and the upper thoracic region.

A Foraminal Compression test (with the head tilted to the left) was positive and produced pain in the right cervical region and the upper thoracic region.

A Shoulder Depression test on the right was positive and produced pain in the upper thoracic region.

A Shoulder Depression test on the left was positive and produced pain in the upper thoracic region.

VERTEBRAL BASILAR INSUFFICIENCY

When tested for evidence of vertebral basilar insufficiency (VBI) Susan showed no signs of interrupted blood flow on the right and no signs of interrupted blood flow on the left.

Mrs. Martin can maintain her balance with her heels together and eyes closed.

The right and left brachioradialis reflex are essentially similar to each other. Susan was tested for wrist clonus and it was determined that wrist clonus is not present on the left and not present on the right.

Muscle testing of the cervical spine flexors caused the patient to stop resisting due to pain.

The strength of the right and left biceps, right and left triceps, right and left wrist flexors, right and left wrist extensors, right and left finger flexors, right and left finger extensors, right and left interossei, right and left anterior deltoids, right and left middle deltoids, right and left posterior deltoids, right and left deltoids, and right and left trapezius were determined to be essentially equal.

A dynamometer was used to evaluate grip strength. The results of evaluating the grip strength of the right hand with the dynamometer are 20 pounds of pressure. The results of evaluating the grip strength of the left hand with the dynamometer are 20 pounds of pressure.

PALPATORY FINDINGS

The right suboccipital region was determined to have mild edema, have mild to moderate spasm of the underlying musculature, and be moderate to severely tender.

The left suboccipital region was determined to have mild edema, have mild spasm of the underlying musculature, and be moderate to severely tender.

The right cervical paraspinal region was determined to have the following:
mild to moderate spasm of the underlying musculature from C1 to T1
moderate to severe tenderness from C1 to T1

The left cervical paraspinal region was determined to have the following:
mild edema
mild spasm of the underlying musculature from C3 to T1
moderate tenderness from C1 to T1

Motion palpation indicated that the following vertebral levels move in an aberrant fashion when Susan is in a relaxed posture: Occiput, C1, and C2.