I.

OVERVIEW
1. Physical medicine and rehabilitation focus on the restoration of function and the
subsequent reintegration of the patient into the community.
2. Therapeutic intervention by physiatrists must be based on proper assessment of the
patient.
 Evaluation of Function
1. After a medical diagnosis is established, the physiatrist must ascertain functional
consequences of the disease.
2. Appropriate clinical evaluation requires the examiner to have a clear understanding
of the distinctions among the disease, body functions, activity limitations, and
participation restrictions.
3. If a disease cannot be eliminated or its severity cannot be reduced through medical
or surgical means, measures are used to minimize its impact on functioning.
 Comprehensiveness of Evaluation
1. The objective of the physiatrist is to eliminate disability and restore functioning.
2. The goal is to empower the individual to attain the fullest possible physical, mental,
social, and economic independence by maximizing activity and participation.
 Interdisciplinary Nature of Evaluation

II. SETTING AND PURPOSE

III. PATIENT HISTORY
 Chief Report of Symptoms
 History of Present Illness
 Functional History
 Communication
1. Four abilities related to speech and language:
a. Listening.
b. Reading.
c. Speaking.
d. Writing.
2. Representative questions include the following:
a. Do you have difficulty hearing?
b. Do you use a hearing aid?
c. Do you have difficulty reading?
d. Do you need glasses to read?
e. Do others find it hard to understand what you say?
f. Do you have problems putting your thoughts into words?
g. Do you have difficulty finding words?
h. Can you write?
i. Can you type?
j. Do you use any communication aids?
 Eating
1. Representative questions include the following:
a. Can you eat without help?
b. Do you have difficulty opening containers or pouring liquids?
c. Can you cut meat?
d. Do you have difficulty handling a fork, knife, or spoon?
e. Do you have problems bringing food or beverages to your mouth?
f. Do you have problems chewing?
g. Do you have difficulty swallowing solids or liquids?
h. Do you ever choke?
i. Do you regurgitate food or liquids through your nose?
 Grooming
1. Representative questions include the following:
a. Can you brush your teeth without help?
b. Can you remove and replace your dentures without help?
c. Do you have problems fixing or combing your hair?
d. Can you apply your makeup independently?
e. Do you have problems shaving?
f. Can you apply deodorant without assistance?
 Bathing
1. Representative questions include the following:
a. Can you take a tub bath or shower without assistance?
b. Do you feel safe in the tub or shower?
c. Do you use a bath bench or shower chair?
d. Can you accomplish a sponge bath without help?
e. Are there parts of your body that you cannot reach?
 Toileting
1. Representative questions include the following:
a. Can you use the toilet without assistance?
b. Do you need help with clothing before or after using the toilet?
c. Do you need help with cleaning after a bowel movement?
 Dressing
1. Representative questions include the following:
a. Do you dress daily?
b. What articles of clothing do you regularly wear?
c. Do you require assistance putting on or taking off your underwear, shirt,
slacks, skirt, dress, coat, stockings, panty hose, shoes, tie, or coat?
d. Do you need help with buttons, zippers, hooks, snaps, or shoelaces?
e. Do you use clothing modifications?
 Bed Activities
1. Representative questions include the following:
a. When lying down, can you turn onto your front, back, and sides without
assistance?
b. Can you lift your hips off the bed when lying on your back?
c. Do you need help to sit or lie down?
d. Do you have difficulty maintaining a seated position?
e. Can you operate the bed controls on an electric hospital bed?
 Transfers
1. Representative questions include the following:
a. Can you move to and from the wheelchair to the bed, toilet, bath bench,
shower chair, standard seating, or car seat without assistance?
b. Can you get out of bed without difficulty?
c. Do you require assistance to rise to a standing position from either a low
or a high seat?
d. Can you get on and off the toilet without help?
  Mobility
o Wheelchair Mobility
1. Representative questions include the following:
a. Do you propel your wheelchair yourself?
b. Do you need help to lock the wheelchair brakes before transfers?
c. Do you require assistance to cross high-pile carpets, rough ground,
or inclines in your wheelchair?
d. How far or how many minutes can you wheel before you must
rest?
e. Can you move independently about your living room, bedroom,
and kitchen?
f. Do you go out to stores, to restaurants, and to friends’ homes?
o Ambulations
1. Any means of movement from one place to another.
2. Representative questions include the following:
a. Do you walk unaided?
b. Do you use a cane, crutches, or a walker to walk?
c. How far or how many minutes can you walk before you must rest?
d. What stops you from going farther?
e. Do you feel unsteady or do you fall?
f. Can you go upstairs and downstairs unassisted?
g. Do you go out to stores, to restaurants, and to friends’ homes?
h. Can you use public transportation (e.g., the bus or subway)
without assistance?
o Operation of Motor Vehicle
1. Representative questions include the following:
a. Do you have a valid driver’s license?
b. Do you own a car?
c. Do you drive your car to stores, to restaurants, and to friends’
homes?
d. Do you drive in heavy traffic or over long distances?
e. Do you drive in low light or after sunset?
f. Do you use hand controls or other automobile modifications?
g. Have you been involved in any motor vehicle accidents or received
any citations for improper operation of a motor vehicle since your
illness or injury?
 Past Medical History
 Neurologic Disorders
 Cardiopulmonary Disorders
 Musculoskeletal Disorders
 Review of Systems
 Constitutional Symptoms
 Head and Neck Symptoms
 Respiratory Symptoms
  Cardiovascular Symptoms
 Gastrointestinal Symptoms
 Genitourinary Symptoms
 Musculoskeletal Symptoms
 Neurologic Symptoms
 Psychiatric Symptoms
 Endocrine Symptoms
 Dermatologic Symptoms
 Patient Profile
 Personal History
o Psychological and Psychiatric History
o Lifestyle
1. Leisure activities can promote both physical health and emotional
health.
2. What sorts of interests do you have?
a. Do you enjoy physical endeavors, sports, the outdoors, and
mechanical avocations (i.e., motor oriented) more than sedentary
activities?
b. Are you more interested in intellectual pursuits (i.e., symbol
oriented) than physical endeavors?
c. Do you derive the most pleasure from social interactions,
organizations, and group functions (i.e., interpersonally oriented)?
d. Have you been actively pursuing any of these interests?
o Diet
o Alcohol and Drugs
 Social History
o Family
o Home (house)
 Vocational History
o Education and Training
o Work History
o Finances
 Family History
IV. PHYSICAL EXAMINATION
1. The physical examination performed by the physiatrist has much in common with the
general medical examination.
2. The physiatrist still has two principal tasks:
a. To scrutinize the patient for physical findings that can help define the functional
impairments emanating from the disease.
b. To identify the patient’s remaining physical, psychological, and intellectual strengths
that can serve as the base for reestablishing functioning.
3. Physical medicine and rehabilitation emphasizes the orthopedic and neurologic
examinations and makes assessment of function an integral part of the overall physical
examination.
 Vital Signs and General Appearance
 Integument and Lymphatics
 Head
 Eyes
 Ears
 Nose
 Mouth and Throat
 Neck
 Chest
 Heart and Peripheral Vascular System
 Abdomen
 Genitourinary System and Rectum
 Musculoskeletal System
 Inspection
 Palpation
 ROM Assessment
1. When identifying a starting point for measuring the ROM of a joint, we prefer
to regard the anatomical position as the baseline (zero starting point).
2. If rotation is being measured, the midway point between the normal rotation
range should be the zero-starting point.
3. When the patient does not assist the examiner during an assessment, the
measurement is a passive ROM.
4. If the patient performs the ROM maneuver without assistance, then the range
is an active ROM.
 Joint Stability Assessment
1. Joint stability is the capacity of the structural elements of a joint to resist the
forces of an inappropriate vector.
2. It is determined by the degree of bony congruity, cartilaginous and capsular
integrity, and ligament and muscle strength and by the forces applied to the
joint.
 Muscle Strength Testing
1. Manual muscle testing provides an important means of assessing strength but
also can be used to assess weakness.
 2. UMN and LMN weakness characteristics.
V. ANATOMICAL INFORMATION REQUIRED TO TEST INDIVIDUAL MUSCLE STRENGTH
 Trapezius
 Action
 Test
 Participating Muscles
 Rhomboids
 Action
 Test
 Participating Muscles
 Serratus Anterior
 Action
 Test
 Participating Muscles
 Supraspinatus
 Infraspinatus
 Pectoralis Major
 Latissimus Dorsi
 Teres Major
 Deltoid
 Subscapularis
 Biceps; Brachialis
 Triceps
 Brachioradialis
 Supinator
 Extensor Carpi Radialis Longus
 Extensor Carpi Radialis Brevis
 Extensor Carpi Ulnaris
 Extensor Digitorum Communis
 Abductor Pollicis Longus
 Extensor Pollicis Brevis
 Extensor Pollicis Longus
 Pronator Teres
 Flexor Carpi Radialis
 Palmaris Longus
 Flexor Carpi Ulnaris
 Flexor Digitorum Superficialis
 Flexor Digitorum Profundus
 Flexor Pollicis Longus
 Abductor Pollicis Brevis
 Opponens Pollicis
 Flexor Pollicis Brevis
 Hypothenar Muscles
 Interossei
  Adductor Pollicis
 Flexors of the Neck
 Extensors of the Neck
 Diaphragm
 Intercostal Muscles
 Anterior Abdominal Muscles
 Extensors of the Back
 Iliopsoas
 Adductor Magnus, Longus, Brevis
 Abductor of the Thigh
 Medial Rotators of the Thigh
 Lateral Rotators of the Thigh
 Gluteus Maximus
 Quadriceps Femoris
 Hamstrings
 Anterior Tibialis
 Extensor Hallucis Longus
 Extensor Digitorum Longus
 Extensor Digitorum Brevis
 Peroneus Longus, Brevis (Fibularis Longus, Brevis)
 Gastrocnemius; Soleus
 Posterior Tibialis
 Long Flexors of the Toes
 Intrinsic Muscles of the Foot
VI. NEUROLOGIC EXAMINATION
 Mental Status
 Level of Consciousness
 Cognitive Evaluation
 Orientation
 Attention
 Recall
 General Fund of Information
 Calculations
 Proverbs
 Similarities
 Judgement
 Speech and Language Function
 Listening
 Reading
 Speaking
 Writing
 Cranial Nerves
 Cranial Nerve I (Olfactory)
 Cranial Nerve II (Optic)
  Cranial Nerve III (Oculomotor), IV (Trochlear) and VI (Abducens)
 Cranial Nerve V (Trigeminal)
 Cranial Nerve VIII (Vestibulocochlear)
 Cranial Nerve VII (Facial), IX (Glossopharyngeal), X (Vagus) and XII (Hypoglossal)
 Cranial Nerve XI (Accessory)
 Reflexes
 Muscle Stretch Relfexes
 Superficial Reflexes
 Pathologic Reflexes
 Central Motor Integration
 Muscle Tone
 Coordination
 Alternate Motion Rate
 Involuntary Movements
 Apraxia
 Sensations
 Superficial Sensations
 Deep Sensations
 Cortical Sensations
 Perception
 Agnosia
 Right-Left Disorientation
 Other Perceptual Tests
VII. FUNCTIONAL EXAMINATION
 Eating
 Grooming
 Bathing
 Toileting
 Dressing
 Bed Activities
 Transfers
 Wheelchair Mobility
 Ambulation
 Operation of a Motor Vehicle
 Quantitation on Function
VIII. SUMMARY AND PROBLEM LIST