Based on the progress report dated 11/14/16 by Kenneth Pace, D.C. the patient complains of lower back pain which radiates to the left lateral thigh, legs and toes. She is unable to perform her normal duties.
On examination, lumbar range of motion is improved in flexion to 60 degrees, extension to 10 degrees, bilateral rotation to 20 degrees, left lateral flexion to 10 degrees and right lateral flexion to 20 degrees. Decreased intersegmental range of motion was observed by standard motion palpation at T10/11/12, L4, L5 and S1 and left sacroiliac joint. …show more content…
She is antalgic in flexion.
IW was diagnosed with lumbar facet syndrome, rib sprain/strain, sacroiliac sprain/strain, muscle spasms and thoracic sprain/strain.
Recommendation was made to continue spinal manipulation 3 times weekly for 4 weeks with re-evaluation to reduce muscle spasms and stiffness and for muscle re-education, increase joint mobility and for edema