Marcel Zardo, R.M.T.

380 Eramosa Rd., Unit 28 Guelph, ON N1E 6R2 Phone: 519 767 9950 Fax: 519 767 9819 E-Mail: marcelzardormt@eramosaphysio.com Web: www.eramosaphysio.com

November 15, 2013

Mr. Smith Blue Cross Insurance Company 185 The West MallSuite 610Etobicoke, Ontario M9C 5P1

Dear Mr. Smith: Mr. Smith you have asked me to assess Ms. Maria Hatfield and to answer your questions about her current health situation and prognosis. This is in respect to Ms. Hatfields insurance claim to your company, Blue Cross, to cover her massage therapy treatment as requested by her doctor, Dr. Gary Wallace, M.D., family physician. The initial assessment for Ms. Hatfield occurred on September 1, 2013 and treatment had ended on November 10, 2013. Regards, Marcel Zardo 1. Professional Qualifications My name is Marcel Zardo and I have been registered practicing massage therapist at a multidisciplinary clinic down town Guelph. I my qualifications R.M.T. and my specialty of my practice is in sport injuries, chronic stress injuries and postural dysfunction. I have been a R.M.T. since 2012 while taking extra courses in postural awareness and spinal orthopedics. 2. Patient Profile/History/Symptoms Ms. Maria Hatfield is a active 35 year old woman who is very health and active with sports. Ms. Hatfield was on her daily jog when her foot went over the curb, where she broke her ankle. She had surgery to realign her fibula. There was four pins and a bar but into her leg. This severely affected her as her job requirement as a personal trainer is to be standing most of her time. For roughly 8-10 hours a day she is on her feet working with clients. Ms. Hatfield also doesnt 3. Assessment 10/10/2012 The initial assessment was conducted on September 1, 2013. Before the initial assessment of Ms. Hatfield, looking over what the surgeons notes were about what was done to her leg I was able to get a better understanding of what was going on in the healing process. There was restriction in all of her ranges of motion (active, passive and restricted) and all of those are accompanied by pain. During the postural assessment, foot arch had collapsed and muscle wasting in her entire calf. Upon further palpation trigger point were found in the gastrocnemius, soleus, tibialsis posterior and anterior that had seen little use due to the cast. Her pain while walking was 6/10 on the visual analog scale. A reassessment was conducted after the first month. 4. Clinical Suspicion My clinical hypothesis there are contractures with in her legs muscle and muscle wasting do to lack of use.

5. Recommendations for Outcomes of Care The long-term goal is to help regain functionality of Ms. Maria Hatfields ankle and leg. The time that would be needed to achieve this goal is very time consuming and precious. 6. Recommendations for Treatment Long-term treatment plan: 22 treatment sessions First plan: 2x 1 hour treatment time /week for 8 weeks Second plan: 1x 1 hour treatment time /week for 6 weeks Reassess after short-term treatment plan: is to treat trigger point and adhesions found with in the muscle. Also to prevent loss of range of movement of the ankle joint from the cast. Techniques to be used: Intended effects: Decrease hypertonicity and increase pliability in Tibialis anterior, Tibialis posterior and gastrocnemius. Decrease trigger points and restore normal resting tension in gastrocnemius and soleus. Restore normal range of motion in calcaneal talo-fibular joint. Normalize muscle imbalances to regain structural support.

Home remedial exercises: Hydrotherapy (heat and cold applications) to ankle region and back of calves Passive stretching for soleus and gastrocnemius Thermaphore (heat modality) to gastrocnemius Effleurage, specific compression, broad contact compression, stripping, passive stretch, gentle PNF, fascial spreading, petrissage, joint mobilizations, and frictioning Active range of motion and strengthening exercises for the ankle Passive stretching and resistance exercises Decrease trigger points and restore normal resting tension in gastronemius Restore normal range of motion Normalize muscle imbalances to regain structural support

7. Clincal Conclusions Ms. Maria Hatfields daily living activities are severely restricted and hindered by the pain caused by contracture in the muscle from her inflamed and weakened calf muscles, which is part of the healing process that the body takes part in. Massage therapy is recommended to treat the acute symptoms of this syndrome so that chronic limitations in movement can be corrected with ongoing treatments. By doing so, this will help Ms. Hatfield increase her functionability in her activities and return to work to perform her job duties successfully.

Sincerely,

Marcel Zardo R.M.T.