DOI: 7/5/2016. Patient is a 54-year-old male technician who sustained injury while carrying a work ladder back to truck when the ladder lost balance and jerked, and injured his low back and right hip. Per OMNI entry, he was initially diagnosed with possible herniated lumbar disc with radiculopathy down the right leg.
Per the IME report dated 08/25/16, the patient came under the care of medication, PT and acupuncture. At this time, he is receiving PT and acupuncture, two times per week. IW was diagnosed with lumbar sprain/strain. It was opined that PT is reasonable, related and necessary 1 time per week for 4 weeks, after which IW should be re-evaluated. A home exercise program is also recommended. Maximum medical improvement has not been …show more content…
Acupuncture needling was performed on this visit, as well as gentle stretches performed after the treatment. IW will continue acupuncture and PT.
Based on the medical report dated 12/29/16, the patient complains of active lumbar pain, rated 6-7/10 with active and worse right leg radiculopathy, rated 6-8/10. Right leg is noted to have weakness, with history of buckling. IW is planning to pursue lumbar spinal surgery. It was noted that rehabilitation and acupuncture is helping. Treatments have prevented worsening of pain and is allowing the patient to work, pending spine surgery. Patient is working full-time.
On examination of the lumbar spine, the paraspinal muscles are tender upon palpation, bilaterally from L4-S1, worse at the L5 level. There is radicular pain into the right leg. Careful palpation reveals muscle spasms with associated trigger points in the bilateral lumbar paraspinal muscles. There is restriction of movement due to pain and stiffness. Straight leg raise is positive on the right at 30 degrees. Of note, ultrasound examination revealed muscle spasms in the quadratus lumborum and in the lumbar paraspinal and deeper psoas
Per the IME report dated 08/25/16, the patient came under the care of medication, PT and acupuncture. At this time, he is receiving PT and acupuncture, two times per week. IW was diagnosed with lumbar sprain/strain. It was opined that PT is reasonable, related and necessary 1 time per week for 4 weeks, after which IW should be re-evaluated. A home exercise program is also recommended. Maximum medical improvement has not been …show more content…
Acupuncture needling was performed on this visit, as well as gentle stretches performed after the treatment. IW will continue acupuncture and PT.
Based on the medical report dated 12/29/16, the patient complains of active lumbar pain, rated 6-7/10 with active and worse right leg radiculopathy, rated 6-8/10. Right leg is noted to have weakness, with history of buckling. IW is planning to pursue lumbar spinal surgery. It was noted that rehabilitation and acupuncture is helping. Treatments have prevented worsening of pain and is allowing the patient to work, pending spine surgery. Patient is working full-time.
On examination of the lumbar spine, the paraspinal muscles are tender upon palpation, bilaterally from L4-S1, worse at the L5 level. There is radicular pain into the right leg. Careful palpation reveals muscle spasms with associated trigger points in the bilateral lumbar paraspinal muscles. There is restriction of movement due to pain and stiffness. Straight leg raise is positive on the right at 30 degrees. Of note, ultrasound examination revealed muscle spasms in the quadratus lumborum and in the lumbar paraspinal and deeper psoas