Wheel chair assessment Form

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How do we measure the clients ability for the wheel chair use? It is a big question for the rehabilitation professionals and the answer is simple the western world says by assessments. I have used a western world assessment tool and did some modification in it. This was the tool that I was using to document the clients ability for the wheelchair use and referral. We in India in disability sector has limited resources and we need to think of methods to develop our skills in rehabilitation. I feel by sharing our skills we may do so. If you have any similar tools, do share it in the forum. If you have any suggestions ro comments please share with me at physionalin1@indiatimes.com

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Wheel chair assessment Form

  1. 1. College for Vocational Training Wheelchair assessment and referral formInstructionsA current wheelchair assessment of a wheelchair must be conducted by a Physiotherapist must be completed foror modifications (including new system seating’s)InformationFirst name - Last Name-Date of Birth- Date of Assessment-Height - Weight-Diagnosis-I Neurological factorsIndicative muscle tone: Hypertonic Hypotonic Abs. Fluctuating othersDescribe muscle tone:Describe active movements affected by muscle tone:Describe passive movements affected by muscle tone:Describe reflexes present(if any):II. Postural ControlHead control Good Fair Poor NoneTrunk control Good Fair Poor NoneUpper extremities Good Fair Poor NoneLower extremities Good Fair Poor NoneDescription and pictoral representation of posture:III.Medical surgical history and plans:Is there any history of decubitus/skin breakdown? Yes NoIf yes please explain:
  2. 2. Describe orthopedic conditions and/ or range of motion requiring special consideration (i.e., contractures,degree of spinal curvature, etc.):      Describe other physical limitation or concerns (i.e., respiratory):Describe any recent changes in medical/Physical/functional status:Brief description if the child/adult has undergone any surgery:IV. Functional assessmentAmbulatory status: Non ambulatory With assistance Short distance only Community ambulatoryDescription:Indicate the child’s /adults ambulatory potential: Already using a wheel chair Expected in 1 year Not expected Expected in future __ Years.Description:IV. Functional assessment:Is the child/adult totally dependent on W/C? Yes NoIf No, please explain:Indicate the child/adults transfer capacities: Maximum assistanceModerate assistance Minimum assistance NoneNotes:Is the child/adult tube fed? Yes NoIf yes please explain:Feeding: Maximum assistance Moderate assistance Minimum assistance NoneNotes:
  3. 3. Dressing: Maximum assistance Moderate Minimum assistance NoneNotes: He needs full assistance in dressing and undressing.Describe the activities performed in wheelchair: (Mobility,feeding,socializing with peers, school, home, family,engaging in community activity)TRANSPORTATION: Car Van Bus Bike Other : Sits in wheelchair during transportWhere is w/c stored during transport? Tie Downs Self Driver Drive while in Wheelchair yes noEmployment:Specific requirements pertaining to mobilitySchool:Specific requirements pertaining to mobilityOther: FUNCTIONAL/SENSORY PROCESSING SKILLS:Handedness: Right Left NA Comments:Functional Processing Skills for Wheeled Mobility Processing Skills are adequate for safe wheelchair operationComments: COMMUNICATION:Verbal Communication WFL receptive WFL expressive Difficult to understand non-communicative Uses an augmentative communication deviceAAC Mount Needed: SENSATION and SKIN ISSUES:Sensation Pressure Relief: Intact Impaired Absent Able to perform effective pressure relief : Yes No Hyposensate Hypersensate Method: If not, Why?: DefensivenessLevel of sensation:Skin Issues/Skin IntegrityCurrent Skin Issues Yes No History of Skin Issues Yes Hx of skin flap surgeries Yes No Intact Red area Open Area No Where ________________________ Where When _________________________ Scar Tissue At risk from prolonged sittingWhere ___________________________ ________________________ When _________________________
  4. 4. Complaint of Pain: Please describe ADL STATUS (in reference to wheelchair use): Indep Assist Unable Indep Not Comments with assessed EquipDressingEating Describe oral motor skillsGrooming/HygieneMeal PrepIADLS Comments:Bowel Mngmnt: Continent Incontinent Accidents Comments:Bladder Mngmnt: Continent Incontinent Accidents CURRENT SEATING / MOBILITY:Current Mobility Base: None Dependent Dependent with Tilt Manual Scooter Power Type of Control:Current Condition of Mobility Base:Current Seating System: Age of Seating System: COMPONENT MANUFACTURER/CONDITIONSeat BaseCushionBackLateral trunk supportsThigh supportKnee supportFoot SupportFoot strapHead SupportPelvic StabilizationAnterior Chest/ShoulderSupportUE SupportOtherWhen relevant: Overall seat height Overall w/c length Overall w/c widthDescribe posture inpresent seating system: V. Environmental assessment Describe the place where Wheel chair is going to be used(home/school):
  5. 5. Is the home/School accessible for W/C? Yes NoAre there ramps in home/School? Yes No Needs modification RECOMMENDATION / GOALS : MANUAL WHEELCHAIR  POV POWER WHEELCHAIR: POSITIONING SYSTEM(TILT/RECLINE) SEATING WHEELCHAIR SKILLS: Indep Assist Dependent/ N/A Comments unableBed ↔ w/c Chair Transfersw/c ↔ Commode Transfers Manual w/c Propulsion: UE or LE strength and Arm : left right Both endurance sufficient to participate in Foot: left right Both ADLs using manual wheelchairOperate Scooter Strength, hand grip, balance , transfer appropriate for use. Living environment appropriate for scooter use.Operate Power w/c: Std. Joystick Safe Functional DistanceOperate Power w/c: w/ AlternativeControls Safe Functional Distance MOBILITY/BALANCE: Balance Transfers Ambulation Sitting Balance: Standing Balance Independent Independent WFL WFL Min Assist Ambulates with Asst Uses UE for balance in sitting Min assist Mod Asst Ambulates with Device Min Assist Mod assist Max assist Indep. Short Distance Only Mod Assist Max assist Dependent Unable to Ambulate Max Assist Unable Sliding Board Unable Lift / Sling RequiredComments:
  6. 6. MAT EVALUATION : A F G C H B I D J K L E M N O Measurements in Sitting: Left Right A: Shoulder Width B: Chest Width H: Seat to Top of Shoulder C: Chest Depth (Front – Back) I: Acromium Process (Tip of Shoulder) D. Hip width J: Inferior Angle of Scapula E. Between Knees K: Seat to Elbow F. Top of Head L: Seat to Iliac Crest G. Occiput M: Upper leg length ++ Overall width (asymmetrical width for N: Lower leg length windswept legs or scoliotic posture O: Foot LengthAdditional Comments:Hamstring flexibility: Pelvis to thigh angle accommodate greater than 90 Thigh to calf angle accommodate less than 90Describe Reflexes/tonal influence on body:
  7. 7. COMMENTS:POSTURE: Anterior / Posterior Obliquity Rotation-Pelvis P E L V I Neutral Posterior WFL R elev l elev WFL Right Left S Anterior Anterior Anterior Fixed Other Fixed Other Fixed Other Partly Flexible Partly Flexible Partly Flexible Flexible Flexible FlexibleTRUNK Rotation-shoulders and upper Anterior / Posterior Left Right trunk Neutral WFL ↑ Thoracic ↑ WFL Convex Convex Left-anterior Lumbar Kyphosis Left Right-anterior Lordosis Right c-curve s-curve multiple Fixed Flexible Fixed Flexible Fixed Flexible Partly Flexible Other Partly Flexible Partly Flexible Other Other Describe LE Neurological Influence/Tone: Position Windswept Hip Flexion/Extension Limitations: H I P    S Neutral Abduc ADduct Neutral Right Left
  8. 8. Fixed Fixed Other Subluxed Partly Flexible Partly Flexible Hip Internal/External Dislocated Range of motion Limitations: Flexible Flexible Knee R.O.M. Foot Positioning Left Right WFL L RKNEES WFL WFL ROM concerns: & Limitations Dorsi-Flexed L R LimitationsFEET Plantar Flexed L R Inversion L R Eversion L R COMMENTS:Posture: Good Head Control Describe Tone/Movement HEAD of head and Neck: Functional & Flexed Extended Adequate Head Control Rotated L Lat Flexed Limited Head Control NECK L Rotated R at Flexed R Cervical Hyperextension Absent Head ControlUpper R.O.M. for Upper DescribeExtremity SHOULDERS Extremity Tone/Movement of UE: WNL WFL Limitations: Left Right Functional Functional elev / dep elev / dep UE Strength Concerns: pro-retract pro- N/A retract None subluxed subluxed Concerns: R.O.M. ELBOWS Left Right
  9. 9. Strength concerns: Left Right Strength / Dexterity:WRIST& FistingHAND Goals for Wheelchair Mobility Independence with mobility in the home and motor related ADLs (MRADLs) in the community Independence with MRADLs in the community Provide dependent mobility Provide recline Provide tilt Goals for Seating system Optimize pressure distribution Provide support needed to facilitate function or safety Provide corrective forces to assist with maintaining or improving posture Accommodate client’s posture: current seated postures and positions are not flexible or will not tolerate corrective forces Client to be independent with relieving pressure in the wheelchair Enhance physiological function such as breathing, swallowing, digestion Simulation ideas: Equipment trials: State why other equipment was unsuccessful: SEATING COMPONENT RECOMMENDATIONS AND JUSTIFICATION Component Manuf/mod/size Justification Seat Cushion accommodate impaired stabilize pelvis sensation accommodate obliquity decubitus ulcers present accommodate multiple prevent pelvic extension deformity low maintenance neutralize LE increase pressure
  10. 10. distributionSeat Wedge accommodate ROM Provide increased aggressiveness of seat shape to decrease sliding down in the seatCover Replacement protect back or seat cushionMounting fixed attach seat platform/cushion to mount headresthardware w/c frame swing medial thigh lateral trunk supports swing away for: attach back cushion to w/c support away headrest frame swing lateral supports away for transfers medial thigh support back seat Seat Board support cushion to prevent allows attachment of Back Board hammocking cushion to mobility baseBack provide lateral trunk support provide posterior trunk accommodate deformity support accommodate or decrease tone provide lumbar/sacral support facilitate tone support trunk in midlineLateral pelvic/thigh pelvis in neutral accommodate tonesupport removable for transfers accommodate pelvis position upper legsMedial Knee decrease adduction remove for transfersSupport accommodate ROM alignmentFoot Support position foot stability accommodate deformity decrease tone control positionAnkle strap/heel support foot on foot support provide input to heelloops decrease extraneous protect foot movementLateral trunk R L decrease lateral trunk leaning safetySupports accom asymmetry control of tone contour for increased contactAnterior chest decrease forward movement of added abdominalstrap, vest, or shoulder supportshoulder retractors accommodation of TLSO alignment decrease forward movement of assistance with shoulder trunk control decrease shoulder elevation Component Manuf/mod/size JustificationHeadrest provide posterior head support improve respiration
  11. 11. provide posterior neck support placement of switches provide lateral head support safety provide anterior head support accommodate ROM support during tilt and recline accommodate tone improve feeding improve visual orientationNeck Support decrease neck rotation decrease forward neck flexionUpper R L decrease edema decrease gravitational pull onExtremity decrease subluxation shouldersSupport control tone provide midline positioning Arm trough provide work surface provide support to increase Posterior hand UE function placement forsupport AAC/Computer/EADL provide hand support in natural ½ tray position full tray swivel mountPelvic stabilize tone pad for protection over boneyPositioner decrease falling out of chair/ prominence Belt **will not decrease potential for prominence comfort SubASIS bar sliding due to pelvic tilting special pull angle to control prevent excessive rotation rotation Dual PullBag or pouch Holds: diapers catheter/hygiene medicines special food ostomy supplies orthotics clothing changesOther
  12. 12. Recommendations/ Modifications in the W/C: Signature of the PT

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