On 11/14/2016, the claimant presented with a low back pain and neck soreness. It was noted that her upper back was much better. Neuromuscular exercises were recommended to further increase the range of motion and core stability. The claimant had a total of 6 completed sessions to date.
The Report dated 11/16/2016, stated that the claimant was doing better. According to the provider, thoracic stability and extension were needed.
On 11/30/2016, the claimant stated that she was 50% better. She also reported that lifting and carrying heavy objects have been improved. The pain was rated at 5/10. She was diagnosed with cervicalgia, other intervertebral disc degeneration of the thoracic spine, other form of scoliosis of the lumbar region, as well as spondylosis without myelopathy or radiculopathy of the thoracic region. According to the provider, the claimant has made functional gains and her overall outcome measure has been improved. However, she continued having limited stability and muscle guarding. Therapy was suggested to further improve function. On 12/02/2016, it was mentioned that the claimant was feeling better. According to the provider, the claimant will benefit from more core stability for her upper trunk. On 12/05/2016, the claimant complained of low back pain. The claimant has gained more control of her thoracic spine. She completed a total of 12 physical therapy sessions to date. She was again evaluated on 12/08/2016. The claimant still presented with a mild low back pain and mild tension in the neck. She had difficulty in core and hip stabilization. Continued therapy was recommended. On 12/12/2016, the claimant complained of low back pain and a little bit of neck pain. According to the provider, the claimant has gained some stability. On 12/14/2014, it was noted that the claimant had neck and back soreness. As per the provider, the claimant has gained stability with the corrected posture. The claimant presented with an increased neck and low back pain on …show more content…
Upon assessment, she progressed with stabilization exercise and required continual cueing to engage abdominal muscles and serratus anterior.
On 01/13/2017, the claimant presented with low back pain. Her thoracic spine pain was much better. Upon assessment, the claimant gained a significant improvement as evidenced by a decreased pain following STM.
On 03/02/2017, the claimant presented with neck and thoracic spine pain rated at 7/10. She presented with some improvement. The plan of care included continued therapy to further increase the range of motion and spinal mobility.
The Physical Therapy Note dated 03/06/2017, stated that the claimant felt sick after her last physical therapy session. She also presented with soreness in her neck, upper trapezius, and mid back. According to the provider, the claimant had some thoracic mobility limitations. The claimant had great relief from the mobilizations.
On 03/08/2017, the claimant complained of pain in the mid-thoracic and pain at the base of the neck rated at 6/10. Upon assessment, it was noted that the claimant had a decreased pain following treatment and continued to have limited thoracic extension and rotation. Continued therapy was