Abstract
A patient with a chronic lower trapezius muscle strain was seen for physical therapy treatment for 8 sessions from 7/14/15 to 8/11/15 at an outpatient physical therapy clinic. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with the numeric pain rating scale, goniometry, manual muscle tests, observation, patient report and the Disabilities of the Arm, Shoulder and Hand Questionnaire, and a plan of care was established. Main goals for the patient were to reduce pain, improve strength, improve posture and improve ability to perform instrumental activities of daily living. Main interventions used were functional strengthening and stretching. The patient improved strength, motor control and sequencing, gait speed, balance, and functional independence. The patient was discharged to home with a home exercise program and with possible follow-up for outpatient physical therapy pending insurance approval.