Neurologic/Geriatric>>Lower Extremity Spasticity Evaluation Template - 1/5/2007
Lower Extremity Spasticity Evaluation
Subjective/History (General):
Impact of spasticity
ADL function
Pain
Contracture/joint deformity
Skin integrity
Spasticity Intervention History:
(Oral Medications, Intrathecal Baclofen, Phenol Injections, Surgery, Botox Injections)
Objective findings:
A. ROM (left/right) PROM AROM MMT
1. Hip flexion
2. Hip extension
3. Hip abduction
4. Hip adduction
5. Hip internal rotation
6. Hip external rotation
7. Knee flexion
8. Knee extension
9. Ankle dorsiflexion
10. Ankle plantar flexion
11. Ankle inversion
12. Ankle eversion
13. Toe flexion (2-5)
14. Great toe flexion
15. Toe extension (2-5)
16. Great toe extension
17. Mid-foot adduction
Joint deformities:
1. Selective control:
2. Synergy:
i. Flexion- strong, moderate, weak, functional, non-functional
ii. Extension- strong, moderate, weak, functional, non-functional
3. Trunk and limb posture in standing:
C. Coordination:
1. Seated:
2. Standing:
D. Tone (Modified Ashworth Scale):
1. Hip flexion
2. Hip extension
3. Hip abduction
4. Hip adduction
5. Hip internal rotation
6. Hip external rotation
7. Knee flexion
8. Knee extension
9. Ankle dorsiflexion
i. Tibialis anterior (dorsiflexion/inversion)
ii. Peroneals (plantaflexion/eversion)
10. Ankle plantar flexion
i. Gastocnemius: (knee flexion, plantarflexion)
ii. Soleus: (plantarflexion)
iii. Tibialis posterior (plantaflexion/inversion)
11. Ankle inversion
i. Tibialis anterior
ii. Tibialis posterior
12. Ankle eversion
13. Toes flexion
i. Flexor Hallucis Longus (plantarflexion/inversion of foot, flexion of great toe)
ii. Flexor Hallucis Brevis (flexion of great toe)
iii. Flexor Digitorum Longus (plantarflexion/inversion of foot, flexion of toes)
iv. Flexor Digitorum Brevis (flexion of toes 2-5)
14. Toes extension
i. Extensor Hallucis Longus (dorsflexion/inversion foot, extension of great toe)
ii. Extensor digitorum longus (dorsiflexion/eversion foot, extension of toes)
iii. Extension Digitorum Brevis (extends toes 2-5)
iv. Plantar interossei (toe adduction)
v. Dorsal Interossei (toe abduction)
E. Posture/Seating & Positioning:
F. Functional Mobility
1. Ambulation:
i. Device: FWW, WBQC, NBQC, SPC, no device, AFO
ii. Distance:
iii. Velocity over 10 meters: comfortable- seconds, maximal- seconds
iv. Assistance:
2. Gait Analysis:
3. Transfers: Independent, supervised, stand-by, minimal, moderate, maximal, dependent assist.
4. Bed Mobility: Independent, supervised, stand-by, minimal, moderate, maximal, dependent assist
5. Sitting Balance:
6. Standing Balance:
G. ADL’s:
H. Sensation:
I. Cognition:
Assessment/Recommendations/Plan:
o No further spasticity treatment necessary
o Recommend the consideration of spasticity intervention: (Oral Meds, Intrathecal Baclofen, Phenol Injections):
o Recommend Botox for Passive Positioning or Pain Management
o Recommend Botox for Passive Functional Seating & Positioning to reduce risk of pressure sores and optimize the client’s ability to interact with his/her environment.
o Recommend Botox for improved functional use of his/her upper extremity
o Recommend Botox for improved dynamic balance & gait
SEE CHART FOR RECOMMENDED MUSCLES AND DOSAGE
o Recommend PT
___ Modalities ___ Manual Therapy ___ Therapuetic Ex. ___ Gait Training
o Recommend OT
___ Modalities ___ Manual Therapy ___ Therapuetic Ex. ___ Functional Training
o Recommend lower extremity bracing/orthotics
o Recommend upper extremity splinting
o Recommend serial casting
GOALS:
1. Improve Mobility
2. Improve Functional use of upper/lower extremities
3. Decrease Pain/spasms
4. Increase ROM for:
A. Prevention of Contractures
B. Functional positioning
C. Improved orthotic fit
D. Delay or Prevention of surgery
E. Improved skin integrity/hygiene