Twstrs Rating Scale Form PDF Details

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Form Name	Twstrs Rating Scale Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	twstrs, toronto western spasmodic torticollis rating scale pdf, toronto western spasmodic torticollis rating scale, 2002

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Toronto Western

Spasmodic Torticollisll

Rating Scalele (TWSTRS)11

WE MOVE is pleased to provide this clinical tool for assessing and documenting the status of patients with spasmodic torticollisÑalso known as cervical dystonia. Additional scales and assessment forms are available at

www.wemove.org

This packet contains

¥50 tear-off copies of the TWSTRS examination form

¥A pocket-sized laminated TWSTRS card (at right)

¥Black-and-white versions of the examination form and pocket- sized TWSTRS card for duplication

Presented by WE MOVE

PHONE: 800-437-MOV2 (6682)

E-MAIL: wemove@wemove.org

Production funded in part by an unrestricted educational grant from Allergan.

WE MOVE makes every effort to ensure the accuracy of this publication. Since there are daily advances in medical science, WE MOVE invites you to visit the Web site at www.wemove.org for view the most recent version of this document.

Toronto Western

Spasmodic

Torticollis

Rating Scale

(TWSTRS)11

I. Torticollis Severity Scale (MAXIMUM = 35)

A. Maximal Excursion

1.Rotation (turn: right or left) 0 = None [0¡]

1 = Slight [< 1/4 range, 1¡Ð 22¡]

2 = Mild [1/4 Ð 1/2 range, 23¡Ð 45¡]

3 = Moderate [1/2 Ð 3/4 range, 46¡Ð 67¡] 4 = Severe [> 3/4 range, 68¡Ð90¡]

2.Laterocollis (tilt: right or left, exclude shoulder elevation) 0 = None [0¡]

1 = Mild [1¡Ð15¡]

2 = Moderate [16¡Ð35¡]

©WE MOVEª 2002

1. Consky ES, Lang AE. Clinical assessments of patients with cervical dystonia. In: Jankovic J, Hallett M, eds. Therapy with Botulinum Toxin. New York, NY: Marcel Dekker, Inc.:1994;211-237.

TWSTRS Examination Record [to be completed by the examiner]
Patient			Chart No.
Date	\|	\|	Time	AM PM
MONTH		DAY	YEAR	©WE MOVEª 2002

I. Torticollis Severity Scale (MAXIMUM = 35)

Rate maximum amplitude of excursion asking patient not to oppose the abnormal movement; examiner may use							S C O R E
A. Maximal Excursion distracting or aggavating maneuvers. When degree of deviation is between scores, choose the higher of the two.							S C O R E
1. Rotation	0	1	2	3	4

2. Laterocollis	0	1	2	3

3. Anterocollis or Retrocollis
a. Anterocollis	0	1	2	3
b. Retrocollis	0	1	2	3

4. Lateral shift	0	1

5. Sagittal shift	0	1

B. Duration Factor	0	1	2	3	4	5
(Weighted x 2)		(X 2)	(X 2)	(X 2)	(X 2)	(X 2)

C. Effect of Sensory Tricks	0	1	2

D. Shoulder Elevation/Anterior Displacement	0	1	2	3

E. Range of Motion	0	1	2	3	4

F. Time	0	1	2	3	4


II. Disability Scale (MAXIMUM = 30)				SUBTOTAL SEVERITY



A. Work	0	1	2	3	4	5

B. Activities of Daily Living	0	1	2	3	4	5

C. Driving	0	1	2	3	4	5

D. Reading	0	1	2	3	4	5

E. Television	0	1	2	3	4	5

F. Activities Outside the Home	0	1	2	3	4	5


				SUBTOTAL DISABILITY
III. Pain Scale (MAXIMUM = 20)
III. Pain Scale (MAXIMUM = 20)

A. Severity of Pain (worst + best + (2*usual))/4	Best ____		Worst ____		Usual ____

B. Duration of Pain	0	1	2	3	4	5

C. Disability Due to Pain	0	1	2	3	4	5

INJECTION RECORD ON REVERSE SIDE

SUBTOTAL PAIN

TOTAL TWSTRS SCORE

PHYSICIAN’S SIGNATURE

Injection Record [indicate injection sites on diagrams provided]
Patient				Chart No.
Date	\|		\|	Time	AM PM
	MONTH	DAY	YEAR			©WE MOVEª 2002
						©WE MOVEª 2002
Agent Injected:	BOTOX _____ Units/ml.	Dysport _____ Units/ml.		MYOBLOC/Neurobloc _____ Units in _____ ml.
	Muscle Injected		Units	Volume	Number of	Total	Total
	Muscle Injected		Injected	Injected	Injections	Units	Volume
			Injected	Injected	Injections	Units	Volume

Total Amount Administered _____________ Total Amount Used _____________

Electromyography Utilized?

Yes

		Semispinalis capitis m.
		Splenius capitis m.
	Sternocleidomastoid m.	Spinal accessory nerve
		Spinal accessory nerve
	Scalene muscles:	Levator scapulae m.
	Anterior	Trapezius m.
	Middle	Trapezius m.
	Middle
	Posterior
		Brachial plexus

	Semispinalis capitis m.
	Splenius capitis m.
	Spinal accessory nerve	Sternocleidomastoid m.
	Spinal accessory nerve
	Levator scapulae m.	Scalene muscles:
	Trapezius m.	Anterior
	Trapezius m.	Middle
		Middle
		Posterior
	Brachial plexus

m. = muscle

		Splenius capitis m.
		Levator scapulae m.
	Trapezius m.	Rhomboideus minor m.
		Rhomboideus minor m.
		Rhomboideus major m.
		Supraspinatus m.
Deltoid m.		Infraspinatus m.
		Infraspinatus m.
		Teres major m.
		Teres minor m.
Latissimus		Serratus anterior m.
Latissimus
dorsi m.
		Serratus posterior
		inferior m.
		Oblique internus m.
		Erector spinae m.

Semispinalis m.	Splenius capitis m.
	Sternocleidomastoid m.
	Splenius cervicalis m.
	Longissimus capitis m.
Trapezius m.	Levator scapulae m.
	Rhomboid minor m.
	Rhomboid major m.

PHYSICIAN’S SIGNATURE

Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)

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