Assess Spasticity - Questionnaire

Alert Indikationen, Sicherheitshinweise und Kontraindikationen

*Indicates required field.

What condition is causing spasticity?*

Spinal cord injury
Multiple sclerosis
Stroke
Brain injury
Cerebral palsy
Other (fill in field)

Is spasticity:*

Segmental: Spasticity in one extremity²
Generalised: Spasticity in more than one extremity.²

And is it:*

Mild¹
Severe (interfering with comfort, active or passive function, activities of daily living, mobility, positioning, or caregiver assistance)¹

Does the patient find their spasticity bothersome, painful or impacting their quality of life?*

Yes
No

Is spasticity interfering with (check all that apply):¹*

Comfort (pain/fatigue)

Movement

Transfers

Positioning

Activities of daily living

Caregiver assistance

None of the above

Does the patient have any of the following? (Check all that apply.)*

Hypersensitivity to baclofen

Active infection

Insufficient body mass for a pump

Responsiveness to oral baclofen therapy

Spinal anomalies

None of the above

Which of the following spasticity treatment(s) is the patient currently receiving or has received in the past?*

Oral medication

Bracing/casting

Physical therapy

Occupational therapy

Injections

Orthopedic surgery

Neurosurgery

None of the above

As a result of current/previous spasticity treatments, which of the following results occur? (Check all that apply.)*

Intolerable side effects at effective doses of oral baclofen

Inconsistent tonal reduction

Spasticity is still interfering with activities of daily living or caregiver assistance

Spasticity is causing pain

None of the above

Does your patient: (Check all that apply)*

Use increased tone for functional value

Have impaired renal function

Have a history of autonomic dysreflexia

Have a psychotic disorder or exhibit confusional state

Use central nervous system depressants and/or alcohol

None of the above

Are there concerns with any of the selection recommendations below that you would like to share with the specialist?*

Unrealistic goals¹

Unmanageable mental health issues^1,3

Psychosocial factors affecting compliance (e.g., unreliable transportation, frequent phone number changes)^1,3

Non favorable response to ITB screening test^2,3

Pregnancy or lack of birth control ³

None of the above

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Saulino M., Ivanhoe C.B., McGuire J.R., Ridley B., Shilt J.S., Boster A.L. Neuromodulation 2016 Aug;19(6):607-15.

Lanig IS, New PW, Burns AS, Optimizing the Management of Spasticity in People With Spinal Cord Damage: A Clinical Care Pathway for Assessment and Treatment Decision Making From the Ability Network, an International Initiative. Arch Phys Med Rehabil. 2018 Aug;99(8):1681-1687

Ivanhoe CB, Tilton AH, Francisco GE. Phys Med Rehabil Clin N Am. 2001 Nov; 12(4); 923-38, viii-ix.

PATIENT ASSESSMENT