Follow-up myoActivation Patient Encounter [Heidi]

Follow-up myoActivation Patient Encounter Date: 2024 11 01 "This encounter note reflects a follow-up visit." Change Since Previous Encounter The patient reports a significant reduction in lower back pain, from a 7/10 to a 2/10, since the last treatment session. They also report improved mobility and are now able to bend over to tie their shoes without difficulty, a task that was previously very challenging. The patient states they feel more confident in their ability to perform daily activities. ASSESSMENT Plantar Weight The patient reports that they feel more weight is being distributed on the outside of their left foot, and they are experiencing some discomfort in that area. Postural Symmetry Observation reveals a slight forward head posture and mild asymmetry in the shoulders. There is a slight elevation of the left hip compared to the right. TREATMENT "All myoActivation treatment involves injections of 0.9% normal saline microaliquots precisely targeted to densities within myofascial tissue at palpable painful points." BASE Test Series 1 Extension Arms Raised The patient reported a 3/10 pain in the left trapezius muscle during the test. Range of motion was slightly restricted. After treatment, the pain decreased to 0/10. Extension Arms Down The patient reported no pain during this test. Flexion Arms Down The patient reported no pain during this test. Squat Arms Down The patient reported no pain during this test. Squat Arms Raised The patient reported no pain during this test. Lateral Arch to Patient's Right The patient reported no pain during this test. Lateral Arch to Patient's Left The patient reported no pain during this test. Procedural Treatment 1 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 2 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 2 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 3 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 3 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 4 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 4 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 5 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 5 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 6 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 6 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 7 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 7 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 8 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 8 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch AFTERCARE [Patient's first name] was advised not to undertake exertional activities for the next 5 days. Helpful to change posture every 15-20 minutes. Important not to walk more than 15 minutes at any one time but can engage in short walks multiple times per day. Follow-up appointment scheduled in two weeks to assess progress and adjust treatment plan as needed.