On 11/15/2016, the claimant reported a return of symptoms and stated that she started having spasm while working. On 11/18/2016, the claimant complained of right sacroiliac joint pain and sacrum pain that was described as moderate and constant which was rated as 5/10. There was also mild-moderate and constant right hip pain that was rated as 4/10 as well as moderate and constant neck pain that was rated as 6/10. The neck pain was unchanged since the last visit while the pain in the right sacroiliac joint, sacrum, and right hip were getting better. Examination revealed that there was increased myospasms in the right paralumbar, right parathoracic, and right paracervical muscles. The tenderness over the neck, occiput, right shoulder blade, upper mid back, mid back, low back, sacrum, right sacroiliac joint, right buttock, and both shoulders had decreased since her treatment date.
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She stated that she was being treated with a chiropractor for 4 years and responded favorably to chiropractic treatment but it seemed slower than expected. Electrical stimulation therapy was applied over the low back and neck as well as manual therapy over the right shoulder. Treatment plan included spinal adjustment 3-4 regions at the level of C2, C4, T3, T7, L5, and sacrum and chiropractic manipulation to both wrists and shoulders. She was diagnosed with low back pain, pain in thoracic spine, cervicalgia, myalgia, and pain in the right shoulder. She was advised to continue PT modalities and procedures, pain/anti-inflammatory medicine, and was referred to family doctor for pain management. Her next office visit was scheduled on 11/23/2016 while the estimated return to work is on 01/04/2017 as per Dr. Keith Lewis
She stated that she was being treated with a chiropractor for 4 years and responded favorably to chiropractic treatment but it seemed slower than expected. Electrical stimulation therapy was applied over the low back and neck as well as manual therapy over the right shoulder. Treatment plan included spinal adjustment 3-4 regions at the level of C2, C4, T3, T7, L5, and sacrum and chiropractic manipulation to both wrists and shoulders. She was diagnosed with low back pain, pain in thoracic spine, cervicalgia, myalgia, and pain in the right shoulder. She was advised to continue PT modalities and procedures, pain/anti-inflammatory medicine, and was referred to family doctor for pain management. Her next office visit was scheduled on 11/23/2016 while the estimated return to work is on 01/04/2017 as per Dr. Keith Lewis